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Distler O, Bonderman D, Coghlan JG, Denton CP, Grünig E, Khanna D, McLaughlin VV, Müller-Ladner U, Pope JE, Vonk MC, Di Scala L, Lemarie JC, Perchenet L, Hachulla É. Performance of DETECT Pulmonary Arterial Hypertension Algorithm According to the Hemodynamic Definition of Pulmonary Arterial Hypertension in the 2022 European Society of Cardiology and the European Respiratory Society Guidelines. Arthritis Rheumatol 2024; 76:777-782. [PMID: 38146100 DOI: 10.1002/art.42791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/14/2023] [Accepted: 12/22/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE The evidence-based DETECT pulmonary arterial hypertension (PAH) algorithm is frequently used in patients with systemic sclerosis (SSc) to help clinicians screen for PAH by using noninvasive data to recommend patient referral to echocardiography and, if applicable, for a diagnostic right-sided heart catheterization. However, the hemodynamic definition of PAH was recently updated in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines. The performance of DETECT PAH in identifying patients with a high risk of PAH according to this new definition was assessed. METHODS In this post hoc analysis of DETECT, which comprised 466 patients with SSc, the performance of the DETECT PAH algorithm in identifying patients with a high risk of PAH as defined in the 2022 ESC/ERS guidelines (mean pulmonary arterial pressure [mPAP] >20 mm Hg, pulmonary capillary wedge pressure [PCWP] ≤15 mm Hg, and pulmonary vascular resistance >2 Wood units) was assessed using summary statistics and was descriptively compared to the known performance of DETECT PAH as defined in 2014, when it was developed (mPAP ≥25 mm Hg and PCWP ≤15 mm Hg). RESULTS The sensitivity of DETECT PAH in identifying patients with a high risk of PAH according to the 2022 ESC/ERS definition was lower (88.2%) compared to the 2014 definition (95.8%). Specificity improved from 47.8% to 50.8%. CONCLUSION The performance of the DETECT algorithm to screen for PAH in patients with SSc is maintained when PAH is defined according to the 2022 ESC/ERS hemodynamic definition, indicating that DETECT remains applicable to screen for PAH in patients with SSc.
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Affiliation(s)
- Oliver Distler
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | | | - Ekkehard Grünig
- Heidelberg University Hospital and Deutsches Zentrum für Lungenforschung, Heidelberg, Germany
| | | | | | - Ulf Müller-Ladner
- Justus-Liebig-University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Janet E Pope
- Western University of Canada, London, Ontario, Canada
| | - Madelon C Vonk
- Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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Aggarwal V, Giri J, Visovatti SH, Mahmud E, Matsubara H, Madani M, Rogers F, Gopalan D, Rosenfield K, McLaughlin VV. Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1090-e1107. [PMID: 38450477 DOI: 10.1161/cir.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.
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Channick R, Chin KM, McLaughlin VV, Lammi MR, Zamanian RT, Turricchia S, Ong R, Mitchell L, Kim NH. Macitentan in Pulmonary Arterial Hypertension Associated with Connective Tissue Disease (CTD-PAH): Real-World Evidence from the Combined OPUS/OrPHeUS Dataset. Cardiol Ther 2024:10.1007/s40119-024-00361-w. [PMID: 38451426 DOI: 10.1007/s40119-024-00361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/14/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Data on real-world clinical practice and outcomes of patients with pulmonary arterial hypertension associated with connective tissue disease (CTD-PAH) are scarce. The OPUS/OrPHeUS studies enrolled patients newly initiating macitentan, including those with CTD-PAH. This analysis describes patient characteristics, treatment patterns, outcomes, and safety profiles of patients with CTD-PAH newly initiating macitentan in the US using the OPUS/OrPHeUS combined dataset. METHODS OPUS was a prospective, US, multicenter, long-term, observational drug registry (April 2014-June 2020). OrPHeUS was a retrospective, US, multicenter medical chart review (October 2013-March 2017). The characteristics, treatment patterns, safety, and outcomes during macitentan treatment of patients with CTD-PAH and its subgroups systemic sclerosis (SSc-PAH), systemic lupus erythematosus (SLE-PAH), and mixed CTD (MCTD-PAH) were descriptively compared to patients with idiopathic/heritable PAH (I/HPAH). RESULTS The combined OPUS/OrPHeUS population included 2498 patients with I/HPAH and 1192 patients with CTD-PAH (708 SSc-PAH; 159 SLE-PAH; 124 MCTD-PAH, and 201 other CTD-PAH etiologies). At macitentan initiation for patients with I/HPAH and CTD-PAH, respectively: 61.2 and 69.3% were in World Health Organization functional class (WHO FC) III/IV; median 6-min walk distance was 289 and 279 m; and 58.1 and 65.2% received macitentan as combination therapy. During follow-up, for patients with I/HPAH and CTD-PAH, respectively: median duration of macitentan exposure observed was 14.0 and 15.8 months; 79.0 and 83.0% experienced an adverse event; Kaplan-Meier estimates (95% confidence limits [CL]) of patients free from all-cause hospitalization at 1 year were 60.3% (58.1, 62.4) and 59.3% (56.1, 62.3); and Kaplan-Meier estimates (95% CL) of survival at 1 year were 90.5% (89.1, 91.7) and 90.6% (88.6, 92.3). CONCLUSIONS Macitentan was used in clinical practice in patients with CTD-PAH and its subgroups, including as combination therapy. The safety and tolerability profile of macitentan in patients with CTD-PAH was comparable to that of patients with I/HPAH. TRIAL REGISTRATION OPsumit® Users Registry (OPUS): NCT02126943; Opsumit® Historical Users cohort (OrPHeUS): NCT03197688; www. CLINICALTRIALS gov Graphical abstract available for this article.
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Affiliation(s)
- Richard Channick
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, 37-131 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | | | | | | | | | - Stefano Turricchia
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Medical Affairs, Allschwil, Switzerland
| | - Rose Ong
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Global Epidemiology, Allschwil, Switzerland
| | - Lada Mitchell
- Actelion Pharmaceuticals Ltd, a Johnson & Johnson Company, Statistics & Decision Sciences-Medical Affairs and Established Products, Allschwil, Switzerland
| | - Nick H Kim
- University of California, San Diego, La Jolla, CA, USA
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Kim NH, Chin KM, McLaughlin VV, DuBrock H, Restrepo-Jaramillo R, Safdar Z, MacDonald G, Martin N, Rosenberg D, Solonets M, Channick R. Safety of Macitentan for the Treatment of Portopulmonary Hypertension: Real-World Evidence from the Combined OPUS/OrPHeUS Studies. Pulm Ther 2024; 10:85-107. [PMID: 38184507 PMCID: PMC10881949 DOI: 10.1007/s41030-023-00251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/14/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Portopulmonary hypertension (PoPH) carries a worse prognosis than other forms of pulmonary arterial hypertension (PAH). Data regarding use of PAH-specific therapies in patients with PoPH are sparse as they are usually excluded from clinical trials. This analysis describes patient characteristics, treatment patterns, outcomes, and safety profiles in patients with PoPH newly initiating macitentan in the USA using the OPUS/OrPHeUS combined dataset. METHODS OPUS was a prospective, US, multicenter, observational drug registry (April 2014-June 2020); OrPHeUS was a retrospective, US, multicenter chart review (October 2013-March 2017). Additional information regarding patients' liver disease was retrospectively collected for patients with PoPH in OPUS. RESULTS The OPUS/OrPHeUS dataset included 206 patients with PoPH (median age 58 years; 52.4% female), with baseline cirrhosis and liver test abnormalities reported in 72.8% and 31.6% of patients respectively. Macitentan was initiated as combination therapy in 74.8% of patients and median (Q1, Q3) exposure to macitentan was 11.9 (3.1, 26.0) months. One-year Kaplan-Meier estimates (95% confidence limit, CL) of patients free from all-cause hospitalization and survival were 48.6% (40.7, 56.0) and 82.2% (75.1, 87.4). Of the 96 patients with PoPH in OPUS, 29.2% were classified as in need of liver transplant due to underlying liver disease during the study; transplant waitlist registration was precluded because of PAH severity for 32.1% and 17.9% were transplanted. Hepatic adverse events (HAE) were experienced by 49.0% of patients; the most common being increased bilirubin (16.0%), ascites (7.3%), and hepatic encephalopathy (5.8%); 1.5% and 21.8% of patients discontinued macitentan as a result of HAE and non-hepatic adverse events. CONCLUSION There were no unexpected safety findings in patients with PoPH treated with macitentan. These data add to the evidence supporting the safety and tolerability of macitentan in patients with PoPH. A graphical abstract is available with this article. TRIAL REGISTRATION OPsumit® Users Registry (OPUS): NCT02126943; OPsumit® Historical Users cohort (OrPHeUS): NCT03197688; www. CLINICALTRIALS gov .
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Affiliation(s)
- Nick H Kim
- UC San Diego Health, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, 9300 Campus Point Dr, La Jolla, CA, 92037-7381, USA.
| | | | | | | | | | - Zeenat Safdar
- Houston Methodist, Weill Cornell Medical College, Houston, TX, USA
| | - Gwen MacDonald
- Global Medical Affairs, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Nicolas Martin
- Statistical Decision Science, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Daniel Rosenberg
- Global Epidemiology, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Maria Solonets
- Global Medical Safety, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Richard Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Gillies H, Chakinala MM, Dake BT, Feldman JP, Hoeper MM, Humbert M, Jing Z, Langley J, McLaughlin VV, Niven RW, Rosenkranz S, Zhang X, Hill NS. IMPAHCT: A randomized phase 2b/3 study of inhaled imatinib for pulmonary arterial hypertension. Pulm Circ 2024; 14:e12352. [PMID: 38532768 PMCID: PMC10963589 DOI: 10.1002/pul2.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/14/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
AV-101 (imatinib) powder for inhalation, an investigational dry powder inhaled formulation of imatinib designed to target the underlying pathobiology of pulmonary arterial hypertension, was generally well tolerated in healthy adults in a phase 1 single and multiple ascending dose study. Inhaled Imatinib Pulmonary Arterial Hypertension Clinical Trial (IMPAHCT; NCT05036135) is a phase 2b/3, randomized, double-blind, placebo-controlled, dose-ranging, and confirmatory study. IMPAHCT is designed to identify an optimal AV-101 dose (phase 2b primary endpoint: pulmonary vascular resistance) and assess the efficacy (phase 3 primary endpoint: 6-min walk distance), safety, and tolerability of AV-101 dose levels in subjects with pulmonary arterial hypertension using background therapies. The study has an operationally seamless, adaptive design allowing for continuous recruitment. It includes three parts; subjects enrolled in Part 1 (phase 2b dose-response portion) or Part 2 (phase 3 intermediate portion) will be randomized 1:1:1:1 to 10, 35, 70 mg AV-101, or placebo (twice daily), respectively. Subjects enrolled in Part 3 (phase 3 optimal dose portion) will be randomized 1:1 to the optimal dose of AV-101 and placebo (twice daily), respectively. All study parts include a screening period, a 24-week treatment period, and a 30-day safety follow-up period; the total duration is ∼32 weeks. Participation is possible in only one study part. IMPAHCT has the potential to advance therapies for patients with pulmonary arterial hypertension by assessing the efficacy and safety of a novel investigational drug-device combination (AV-101) using an improved study design that has the potential to save 6-12 months of development time. ClinicalTrials.gov Identifier: NCT05036135.
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Affiliation(s)
| | - Murali M. Chakinala
- Division of Pulmonary and Critical Care MedicineWashington University in St. LouisSt. LouisMissourIUSA
| | | | | | - Marius M. Hoeper
- Department of Respiratory Medicine and Infectious DiseasesHannover Medical SchoolHannoverGermany
- German Center for Lung Research (DZL)Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH)HannoverGermany
| | - Marc Humbert
- Service de Pneumologieet Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital BicêtreUniversité Paris–Saclay, INSERMUMR_S 999Le Kremlin‐BicêtreFrance
| | - Zhi‐Cheng Jing
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical SciencesSouthern Medical UniversityGuangzhouChina
| | | | - Vallerie V. McLaughlin
- Cardiology Clinic, Frankel Cardiovascular CenterUniversity of MichiganAnn ArborMichiganUSA
| | | | - Stephan Rosenkranz
- Department of Internal Medicine III, Cologne Cardiovascular Research Center, Heart CenterUniversityof CologneCologneGermany
| | | | - Nicholas S. Hill
- Pulmonary Critical Care and Sleep DivisionTufts Medical CenterBostonMassachusettsUSA
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Cascino TM, Schopfer DW, Meyer CS, Zhang N, Barnes GD, McLaughlin VV, Jackson EA, Whooley MA. Exercise Rehabilitation is Underutilized Among Veterans With Pulmonary Hypertension. Am J Cardiol 2023; 207:4-6. [PMID: 37717285 DOI: 10.1016/j.amjcard.2023.08.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan.
| | - David W Schopfer
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Medicine, University of California, San Francisco, California
| | - Craig S Meyer
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Medicine, University of California, San Francisco, California
| | - Ning Zhang
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Medicine, University of California, San Francisco, California
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Elizabeth A Jackson
- Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary A Whooley
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Medicine, University of California, San Francisco, California
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Gomberg-Maitland M, McLaughlin VV, Badesch DB, Ghofrani HA, Hoeper MM, Humbert M, Preston IR, Souza R, Waxman AB, de Oliveira Pena J, Lu JT, Manimaran S, Gibbs JSR. Long-Term Effects of Sotatercept on Right Ventricular Function: Results From the PULSAR Study. JACC Heart Fail 2023; 11:1457-1459. [PMID: 37452806 DOI: 10.1016/j.jchf.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/16/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023]
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Souza R, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Lin J, Johnson-Levonas AO, de Oliveira Pena J, Humbert M, Hoeper MM. Effects of sotatercept on haemodynamics and right heart function: analysis of the STELLAR trial. Eur Respir J 2023; 62:2301107. [PMID: 37696565 PMCID: PMC10512088 DOI: 10.1183/13993003.01107-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/11/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND In the phase 3 STELLAR trial, sotatercept, an investigational first-in-class activin signalling inhibitor, demonstrated beneficial effects on 6-min walk distance and additional efficacy endpoints in pre-treated participants with pulmonary arterial hypertension (PAH). METHODS This post hoc analysis evaluated data from right heart catheterisation (RHC) and echocardiography (ECHO) obtained from the STELLAR trial. Changes from baseline in RHC and ECHO parameters were assessed at 24 weeks. An analysis of covariance (ANCOVA) model was used to estimate differences in least squares means with treatment and randomisation stratification (mono/double versus triple therapy; World Health Organization functional class II versus III) as fixed factors, and baseline value as covariate. RESULTS Relative to placebo, treatment with sotatercept led to significant (all p<0.0001 except where noted) improvements from baseline in mean pulmonary artery (PA) pressure (-13.9 mmHg), pulmonary vascular resistance (-254.8 dyn·s·cm-5), mean right atrial pressure (-2.7 mmHg), mixed venous oxygen saturation (3.84%), PA elastance (-0.42 mmHg·mL-1·beat-1), PA compliance (0.58 mL·mmHg-1), cardiac efficiency (0.48 mL·beat-1·mmHg-1), right ventricular (RV) work (-0.85 g·m) and RV power (-32.70 mmHg·L·min-1). ECHO showed improvements in tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure ratio (0.12 mm·mmHg-1), end-systolic and end-diastolic RV areas (-4.39 cm2 and -5.31 cm2, respectively), tricuspid regurgitation and RV fractional area change (2.04% p<0.050). No significant between-group changes from baseline were seen for TAPSE, heart rate, cardiac output, stroke volume or their indices. CONCLUSION In pre-treated patients with PAH, sotatercept demonstrated substantial improvements in PA pressures, PA compliance, PA-RV coupling and right heart function.
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Affiliation(s)
- Rogerio Souza
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - David B Badesch
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - H Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - J Simon R Gibbs
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | | | | | - Ekkehard Grünig
- Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg, Germany
| | - Grzegorz Kopeć
- The Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Gisela Meyer
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Karen M Olsson
- Hannover Medical School and the German Center for Lung Research, Hannover, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, and Cologne Cardiovascular Research Center (CCRC), Heart Center, University Hospital Cologne, Cologne, Germany
| | | | | | | | - Marc Humbert
- Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France
| | - Marius M Hoeper
- Hannover Medical School and the German Center for Lung Research, Hannover, Germany
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Zghouzi M, Shore S, Mwansa H, Hyder S, Kamdar N, Moles V, Barnes GD, Froehlich JB, McLaughlin VV, Nallamothu BK, Aggarwal V. RACIAL DISPARITIES IN PULMONARY EMBOLISM MORTALITY AMONGST US ADULTS BEFORE AND DURING COVID-19 PANDEMIC. J Am Coll Cardiol 2023. [PMCID: PMC9982987 DOI: 10.1016/s0735-1097(23)02475-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Hoeper MM, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Souza R, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Xu Y, Miller B, Fowler M, Butler J, Koglin J, de Oliveira Pena J, Humbert M. Phase 3 Trial of Sotatercept for Treatment of Pulmonary Arterial Hypertension. N Engl J Med 2023; 388:1478-1490. [PMID: 36877098 DOI: 10.1056/nejmoa2213558] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension is a progressive disease involving proliferative remodeling of the pulmonary vessels. Despite therapeutic advances, the disease-associated morbidity and mortality remain high. Sotatercept is a fusion protein that traps activins and growth differentiation factors involved in pulmonary arterial hypertension. METHODS We conducted a multicenter, double-blind, phase 3 trial in which adults with pulmonary arterial hypertension (World Health Organization [WHO] functional class II or III) who were receiving stable background therapy were randomly assigned in a 1:1 ratio to receive subcutaneous sotatercept (starting dose, 0.3 mg per kilogram of body weight; target dose, 0.7 mg per kilogram) or placebo every 3 weeks. The primary end point was the change from baseline at week 24 in the 6-minute walk distance. Nine secondary end points, tested hierarchically in the following order, were multicomponent improvement, change in pulmonary vascular resistance, change in N-terminal pro-B-type natriuretic peptide level, improvement in WHO functional class, time to death or clinical worsening, French risk score, and changes in the Pulmonary Arterial Hypertension-Symptoms and Impact (PAH-SYMPACT) Physical Impacts, Cardiopulmonary Symptoms, and Cognitive-Emotional Impacts domain scores; all were assessed at week 24 except time to death or clinical worsening, which was assessed when the last patient completed the week 24 visit. RESULTS A total of 163 patients were assigned to receive sotatercept and 160 to receive placebo. The median change from baseline at week 24 in the 6-minute walk distance was 34.4 m (95% confidence interval [CI], 33.0 to 35.5) in the sotatercept group and 1.0 m (95% CI, -0.3 to 3.5) in the placebo group. The Hodges-Lehmann estimate of the difference between the sotatercept and placebo groups in the change from baseline at week 24 in the 6-minute walk distance was 40.8 m (95% CI, 27.5 to 54.1; P<0.001). The first eight secondary end points were significantly improved with sotatercept as compared with placebo, whereas the PAH-SYMPACT Cognitive-Emotional Impacts domain score was not. Adverse events that occurred more frequently with sotatercept than with placebo included epistaxis, dizziness, telangiectasia, increased hemoglobin levels, thrombocytopenia, and increased blood pressure. CONCLUSIONS In patients with pulmonary arterial hypertension who were receiving stable background therapy, sotatercept resulted in a greater improvement in exercise capacity (as assessed by the 6-minute walk test) than placebo. (Funded by Acceleron Pharma, a subsidiary of MSD; STELLAR ClinicalTrials.gov number, NCT04576988.).
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Affiliation(s)
- Marius M Hoeper
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - David B Badesch
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - H Ardeschir Ghofrani
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - J Simon R Gibbs
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Mardi Gomberg-Maitland
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Vallerie V McLaughlin
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Ioana R Preston
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Rogerio Souza
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Aaron B Waxman
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Ekkehard Grünig
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Grzegorz Kopeć
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Gisela Meyer
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Karen M Olsson
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Stephan Rosenkranz
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Yayun Xu
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Barry Miller
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Marcie Fowler
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - John Butler
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Joerg Koglin
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Janethe de Oliveira Pena
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
| | - Marc Humbert
- From the Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Member of the German Center for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover, Hannover (M.M.H., K.M.O.), the Department of Internal Medicine, Universities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio-Pulmonary Institute, Member of the German Center for Lung Research, Giessen (H.A.G.), Thoraxklinik-Heidelberg and the German Center for Lung Research, Heidelberg (E.G.), and the Department of Cardiology, Heart Center, University Hospital Cologne, Cologne (S.R.) - all in Germany; the University of Colorado, Anschutz Medical Campus, Aurora (D.B.B.); the National Heart and Lung Institute, Imperial College London, London (J.S.R.G.); George Washington University, Washington, DC (M.G.-M.); the University of Michigan, Ann Arbor (V.V.M.); Tufts Medical Center (I.R.P.) and Brigham and Women's Hospital (A.B.W.) - both in Boston; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (R.S.), and Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (G.M.) - both in Brazil; the Pulmonary Circulation Center, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland (G.K.); Merck (Y.X., J.K.) and Acceleron Pharma (B.M., M.F., J.B., J.O.P.) - both in Rahway, NJ; and Université Paris-Saclay, INSERM Unité Mixte de Recherche en Santé 999, Hôpital Bicêtre (Assistance Publique-Hôpitaux de Paris), Le Kremlin-Bicêtre, France (M.H.)
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11
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Zghouzi M, Shore S, Mwansa H, Hyder S, Kamdar N, Moles V, Barnes GD, Froehlich JB, McLaughlin VV, Paul TK, Nallamothu BK, Aggarwal V. TEMPORAL MORTALITY TRENDS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION, STROKE, AND PULMONARY EMBOLISM IN THE UNITED STATES. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02466-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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12
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Rich L, Patel N, Hyder S, Moles V, Gurm HS, Agarwal PRACHI, Visovatti S, Haft J, Cascino T, McLaughlin VV, Aggarwal V. SAFETY OF BALLOON PULMONARY ANGIOPLASTY IN THE OUTPATIENT SETTING: THE MICHIGAN MEDICINE EXPERIENCE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01262-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Gillies H, Niven R, Dake BT, Chakinala MM, Feldman JP, Hill NS, Hoeper MM, Humbert M, McLaughlin VV, Kankam M. AV-101, a novel inhaled dry-powder formulation of imatinib, in healthy adult participants: a phase 1 single and multiple ascending dose study. ERJ Open Res 2023; 9:00433-2022. [PMID: 36923571 PMCID: PMC10009698 DOI: 10.1183/23120541.00433-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/16/2022] [Indexed: 11/12/2022] Open
Abstract
Background Oral imatinib has been shown to be effective, but poorly tolerated, in patients with advanced pulmonary arterial hypertension (PAH). To maintain efficacy while improving tolerability, AV-101, a dry powder inhaled formulation of imatinib, was developed to deliver imatinib directly to the lungs. Methods This phase 1, placebo-controlled, randomised single ascending dose (SAD) and multiple ascending dose (MAD) study evaluated the safety/tolerability and pharmacokinetics of AV-101 in healthy adults. The SAD study included five AV-101 cohorts (1 mg, 3 mg, 10 mg, 30 mg, 90 mg) and placebo, and a single-dose oral imatinib 400-mg cohort. The MAD study included three AV-101 cohorts (10 mg, 30 mg, 90 mg) and placebo; dosing occurred twice daily for 7 days. Results 82 participants (SAD n=48, MAD n=34) were enrolled. For the SAD study, peak plasma concentrations of imatinib occurred within 3 h of dosing with lower systemic exposure compared to oral imatinib (p<0.001). For the MAD study, systemic exposure of imatinib was higher after multiple doses of AV-101 compared to a single dose, but steady-state plasma concentrations were lower for the highest AV-101 cohort (90 mg) compared to simulated steady-state oral imatinib at day 7 (p=0.0002). Across AV-101 MAD dose cohorts, the most common treatment-emergent adverse events were cough (n=7, 27%) and headache (n=4, 15%). Conclusions AV-101 was well tolerated in healthy adults, and targeted doses of AV-101 significantly reduced the systemic exposure of imatinib compared with oral imatinib. An ongoing phase 2b/phase 3 study (IMPAHCT; clinicaltrials.gov identifier NCT05036135) will evaluate the safety/tolerability and clinical benefit of AV-101 for PAH.
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Affiliation(s)
| | | | | | | | | | - Nicholas S Hill
- Pulmonary Critical Care and Sleep Division, Tufts Medical Center, Boston, MA, USA
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School and German Centre of Lung Research, Hannover, Germany
| | - Marc Humbert
- Université Paris-Saclay, INSERM, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | - Martin Kankam
- Altasciences Clinical Kansas, Inc., Overland Park, KS, USA
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14
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Coghlan JG, Gaine S, Channick R, Chin KM, du Roure C, Gibbs JSR, Hoeper MM, Lang IM, Mathai SC, McLaughlin VV, Mitchell L, Simonneau G, Sitbon O, Tapson VF, Galiè N. Early selexipag initiation and long-term outcomes: insights from randomised controlled trials in pulmonary arterial hypertension. ERJ Open Res 2023; 9:00456-2022. [PMID: 36687361 PMCID: PMC9841313 DOI: 10.1183/23120541.00456-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/03/2022] [Indexed: 11/12/2022] Open
Abstract
Further understanding of when to initiate therapies in pulmonary arterial hypertension (PAH) is important to improve long-term outcomes. Post hoc analyses of GRIPHON (NCT01106014) and exploratory analyses of TRITON (NCT02558231) suggested benefit of early selexipag initiation on long-term outcomes, despite no additional benefit versus initial double combination on haemodynamic and functional parameters in TRITON. Post hoc analyses investigated the effect of early selexipag initiation on disease progression and survival in a large, pooled PAH cohort. Data from newly diagnosed (≤6 months) PAH patients from GRIPHON and TRITON were pooled. Patients on active therapy with selexipag (pooled selexipag group) were compared with those on control therapy with placebo (pooled control group). Disease progression end-points were defined as per the individual studies. Hazard ratios (HR) and 95% CI for time to first disease progression event up to end of double-blind treatment (selexipag/placebo) +7 days and time to all-cause death up to end of study were estimated using Cox regression models. The pooled dataset comprised 649 patients, with 44% on double background therapy. Selexipag reduced the risk of disease progression by 52% versus control (HR: 0.48; 95% CI: 0.35-0.66). HR for risk of all-cause death was 0.70 (95% CI: 0.46-1.10) for the pooled selexipag versus control group. Sensitivity analyses accounting for the impact of PAH background therapy showed consistent results, confirming the appropriateness of data pooling. These post hoc, pooled analyses build on previous insights, further supporting selexipag use within 6 months of diagnosis, including as part of triple therapy, to delay disease progression.
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Affiliation(s)
- J. Gerry Coghlan
- Royal Free Hospital, London, UK,Corresponding author: J. Gerry Coghlan ()
| | - Sean Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Richard Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Camille du Roure
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Global Medical Affairs, Allschwil, Switzerland
| | - J. Simon R. Gibbs
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Marius M. Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | - Irene M. Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | - Lada Mitchell
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Statistics & Decision Sciences - Medical Affairs and Established Products, Allschwil, Switzerland
| | - Gérald Simonneau
- Hôpital Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - Olivier Sitbon
- Hôpital Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | | | - Nazzareno Galiè
- Alma Mater Studiorum, University of Bologna and IRCCS-S.Orsola University Hospital, Bologna, Italy
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McLaughlin VV, Channick R, Kim NH, Frantz RP, McConnell J, Melendres‐Groves L, Miller C, Ravichandran A, Rodriguez‐Lopez J, Brand M, Leroy S, Wetherill G, Chin KM. Safety of macitentan for the treatment of pulmonary hypertension: Real‐world experience from the OPsumit® USers Registry (OPUS) and OPsumit® Historical USers cohort (OrPHeUS). Pulm Circ 2022; 12:e12150. [PMID: 36381290 PMCID: PMC9661363 DOI: 10.1002/pul2.12150] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 12/05/2022] Open
Abstract
Macitentan is an oral endothelin receptor antagonist for the management of pulmonary arterial hypertension (PAH). The OPsumit® USers Registry (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) medical chart review provide real‐world data for patients newly initiating macitentan. This study aims to describe the characteristics, safety profile, and clinical outcomes of PAH patients newly treated with macitentan in the combined OPUS/OrPHeUS data set. OPUS was a prospective, multicenter, long‐term, observational drug registry from April 2014 to June 2020. OrPHeUS was a retrospective, US, multicenter chart review: observation period October 2013 to March 2017. All analyses were descriptive. At registry closure in June 2020, the combined population consisted of 5654 patients, of whom 81.9% were diagnosed with PAH. For these 4626 patients, median duration of macitentan exposure observed was 14.5 (Q1 = 5.2, Q3 = 29.0) months; idiopathic PAH (54.8%) was the most common form of PAH; macitentan was initiated as monotherapy (37.9%), or as part of double (48.0%) or triple therapy (14.1%); discontinuation due to nonhepatic/hepatic adverse events occurred in 17.1%/0.3% of patients; 9.9% of patients experienced ≥1 hepatic adverse events; Kaplan–Meier estimates showed that at 1 year 59.9% (95% confidence interval: 58.3, 61.5) of patients were free from hospitalization and survival was 90.4% (89.3, 91.3). This analysis of real‐world data from the combined OPUS and OrPHeUS populations demonstrated that macitentan is well tolerated in a large, diverse population of PAH patients, with overall and hepatic safety profiles consistent with previous macitentan clinical trials.
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Affiliation(s)
- VV McLaughlin
- Department of Internal Medicine, Division of Cardiovascular Medicine University of Michigan Ann Arbor MI USA
| | - R Channick
- David Geffen School of Medicine University of California Los Angeles Los Angeles CA USA
| | - NH Kim
- Division of Pulmonary, Critical Care and Sleep Medicine University of California San Diego La Jolla CA USA
| | - RP Frantz
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - J McConnell
- Kentuckiana Pulmonary Associates Louisville KY USA
| | | | - C Miller
- Pulmonary Hypertension and Pulmonary Critical Care Medicine, Piedmont Physicians, Piedmont Healthcare Austell GA USA
| | | | | | - M Brand
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Global Epidemiology Allschwil Switzerland
| | - S Leroy
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Data Science Global Regulatory Affairs Allschwil Switzerland
| | - G Wetherill
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Medical Affairs and Established Products Allschwil Switzerland
- Current affiliation: Biometric Solutions Limited, St Ives Cambridgeshire UK
| | - KM Chin
- Department of Internal Medicine, UT Southwestern Medical Center Dallas TX USA
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Channick R, Chin KM, Kim NH, Ong R, Turricchia S, Mitchell L, McLaughlin VV. Concomitant initiation of combination therapy with macitentan and tadalafil in pulmonary arterial hypertension (PAH) patients with comorbidities: real-world data from OPUS and OrPHeUS. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Guidelines for the management of pulmonary arterial hypertension (PAH) recommend early combination therapy of an endothelial receptor antagonist (ERA) and a phosphodiesterase type-5 inhibitor (PDE5i) [1]. There is, however, limited guidance about the management of PAH patients with comorbidities.
Purpose
To describe the demographics, clinical characteristics, safety, tolerability, and outcomes associated with initiation of the ERA macitentan and the PDE5i tadalafil in patients with comorbidities in the US OPsumit® USers (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) combined dataset.
Methods
This analysis reports data from the OPUS registry (Apr 2014–Jun 2020) and OrPHeUS medical chart review (Oct 2013–Mar 2017) on PAH patients initiating macitentan and tadalafil (M+T) combination therapy, in any order, as concomitant initiation (≤60 days apart, concomitant initiation group). The index date was defined as the start date of the second therapy (i.e., the start of combination therapy). Patients were further grouped by the number of comorbidities present prior to or at macitentan initiation: systemic hypertension, diabetes, renal insufficiency, BMI ≥30 kg/m2, other signs of right heart failure and atrial fibrillation. Results are presented descriptively alongside results for all PAH patients receiving M+T combination therapy (overall M+T group).
Results
Of the 1336 PAH patients that received M+T combination therapy, 431 (32%) were in the concomitant initiation group. In the concomitant initiation and overall M+T groups, respectively: 72% and 68% had ≥1 comorbidity, and the most common were systemic hypertension (47% and 47%), obesity (32% and 26%) and diabetes (23% and 22%). Patients were more likely to be older, male and have idiopathic/heritable PAH with increasing comorbidity burden (Table 1). Patients in the concomitant initiation group were more likely to be incident (median time from diagnosis: 1–2 months vs 9–24 months in the overall M+T group; Table 1). Most patients had ≥1 adverse event (AE); in both groups, patients with a high comorbidity burden (≥3) were more likely to have had an AE and to have discontinued treatment (Table 2). The incidence rate of first all-cause hospitalisation and mortality by comorbidity was comparable between the concomitant initiation and overall M+T groups.
Conclusions
In the real-world, concomitant initiation of M+T is used in PAH patients with comorbidities, usually shortly after diagnosis. Patient characteristics were similar for the concomitant initiation and overall M+T groups, with the exception of time from diagnosis. At index date, age, gender proportion, and PAH aetiology differed between the comorbidity groups. The safety profile of M+T combination therapy in the concomitant initiation group was consistent with that in the overall M+T group.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson
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Affiliation(s)
- R Channick
- University of California Los Angeles , Los Angeles , United States of America
| | - K M Chin
- University of Texas Southwestern Medical Center , Dallas , United States of America
| | - N H Kim
- University of California San Diego , San Diego , United States of America
| | - R Ong
- Actelion Pharmaceuticals Ltd , Allschwil , Switzerland
| | - S Turricchia
- Actelion Pharmaceuticals Ltd , Allschwil , Switzerland
| | - L Mitchell
- Actelion Pharmaceuticals Ltd , Allschwil , Switzerland
| | - V V McLaughlin
- University of Michigan , Ann Arbor , United States of America
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McLaughlin VV, Channick RN, Lynum KSB, Oudiz RJ, Selej M, Tapson VF, Rubin LJ. Using a knowledge translation program to facilitate guideline‐based and evidence‐based patient management: the PAH‐QuERI Extension Program. Pulm Circ 2022; 12:e12134. [PMID: 36172596 PMCID: PMC9469640 DOI: 10.1002/pul2.12134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 06/29/2022] [Accepted: 08/24/2022] [Indexed: 11/23/2022] Open
Abstract
The Pulmonary Arterial Hypertension‐Quality Enhancement Research Initiative Extension Program was designed to support physicians’ adherence to pulmonary arterial hypertension (PAH) guidelines. Guidelines were followed in >95% of patients with functional class (FC) II/III, but for only 28.6% of FC IV patients (Month 36). Low adherence was driven by FC IV patients’ preference to avoid parenteral treatment.
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Affiliation(s)
| | | | | | - Ronald J. Oudiz
- Lundquist Institute for Biomedical Research and Innovation at Harbor‐UCLA Medical Center Torrance California USA
| | - Mona Selej
- Actelion Pharmaceuticals US, Inc. Titusville New Jersey USA
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Hakim H, Meyyappan L, Liu E, Kline-Rogers EM, McDevitt S, Moles V, McLaughlin VV. Abstract 56: Differences Between Chronic Thromboembolic Disease And Chronic Thromboembolic Pulmonary Hypertension Patients At Time Of Presentation. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Approximately 1/3 of acute pulmonary embolism (PE) patients develop chronic thromboembolic disease (CTED), a condition in which a patient’s PE does not resolve after standard anticoagulation therapy. Chronic thromboembolic pulmonary hypertension (CTEPH) can occur in about 3-4% of acute PE patients. Though CTED and CTEPH share an underlying cause, few studies have compared symptom severity, patient history, and other clinical indicators for the two diseases. Moreover, CTED is sometimes considered to be an asymptomatic condition. The symptomatology in CTEPH is thought to be primarily determined by pulmonary hypertension, a characteristic that CTED patients do not share.
Methods:
Data were collected at baseline diagnosis from 24 CTED and 65 CTEPH patients in the University of Michigan Pulmonary Hypertension Registry between 2016-2020. Demographic, 6-minute walk (6MW), echocardiography, past medical history, and brain natriuretic peptide (BNP) data were compared between groups.
Results:
CTED patients were: 1) less symptomatic (better WHO functional class [FC], better predicted 6MW), 2) had more preserved oxygenation during 6MW, 3) had less RV dilation/dysfunction and RA dilation on echo, and 4) lower BNP, than CTEPH patients. Despite this, 54% of CTED patients demonstrated significantly impaired FC (III/IV) without evidence of significant RV dysfunction, exercise hypoxia or volume overload.
Conclusion:
More than half of CTED patients in our study had significantly impaired FC. Further investigation into CTED symptomatology is warranted. CTEPH patients are more symptomatic and present with worse clinical metrics than CTED patients, which may be attributed to more advanced RV dysfunction and higher BNP level. These results may help distinguish CTED v. CTEPH diagnoses earlier, leading to earlier targeted treatment and better outcomes.
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Perkins S, Funes ML, Cheah D, Gordon D, Haft J, Williams D, McLaughlin VV, Moles V, Agarwal P, Cascino T, Shih A, Aggarwal V. SAFE AND EFFECTIVE LESION CROSSING IN BALLOON PULMONARY ANGIOPLASTY: THERAPEUTIC WINDOW FOR A NOVEL DEVICE. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02731-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Gualano S, Price E, Harrod M, Quinn M, Bhave NM, McLaughlin VV, Duvernoy CS, Sandhu G, Kerr EA. EXPLORING BARRIERS AND FACILITATORS TO ADVANCEMENT AMONG WOMEN FACULTY IN CARDIOVASCULAR MEDICINE. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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21
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Galiè N, Gaine S, Channick R, Coghlan JG, Hoeper MM, Lang IM, McLaughlin VV, Lassen C, Rubin LJ, Hsu Schmitz SF, Sitbon O, Tapson VF, Chin KM. Long-Term Survival, Safety and Tolerability with Selexipag in Patients with Pulmonary Arterial Hypertension: Results from GRIPHON and its Open-Label Extension. Adv Ther 2022; 39:796-810. [PMID: 34727317 PMCID: PMC8799580 DOI: 10.1007/s12325-021-01898-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION In the event-driven GRIPHON randomised-controlled trial, the oral prostacyclin receptor agonist selexipag significantly reduced the risk of disease progression (composite primary endpoint of morbidity/mortality), compared with placebo, in patients with pulmonary arterial hypertension (PAH). The ongoing open-label extension study (GRIPHON OL) collects further data on long-term safety, tolerability, and survival of PAH patients treated with selexipag. METHODS Patients randomised to selexipag or placebo in GRIPHON could enter GRIPHON OL either after experiencing a morbidity event during double-blind treatment or at the end of the study. Patients were followed for adverse events (AE) and survival from selexipag initiation up to 3 days and 30 days after end of treatment, respectively. Data are presented up to a cut-off date of 1 September 2019. RESULTS Overall, 953 patients in GRIPHON and GRIPHON OL were treated with selexipag. At the time of selexipag initiation, 81.2% of patients were receiving background PAH therapy. Median (min, max) exposure to selexipag was 31.7 months (0, 106), corresponding to a total of 3054.4 patient-years. The most frequently reported AEs were related to known prostacyclin-related effects or underlying disease. There were 305 (32.0%) patients who experienced an AE leading to treatment discontinuation. Survival during GRIPHON and GRIPHON OL was assessed for the 574 patients randomised to selexipag in GRIPHON. Kaplan-Meier survival estimates (95%CI) at 1, 3, 5 and 7 years were 92.0% (89.4, 94.0), 79.3% (75.4, 82.6), 71.2% (66.5, 75.3) and 63.0% (57.4, 68.1), respectively. CONCLUSIONS These results provide the longest follow-up period published to date for a PAH therapy. The safety profile of selexipag over this extended treatment period was consistent with that observed in GRIPHON. A large proportion of the population was receiving background therapy at selexipag initiation, providing further insight into the long-term safety of selexipag as part of a combination therapy regimen. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT01106014 and NCT01112306.
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Affiliation(s)
- Nazzareno Galiè
- Alma Mater Studiorum, University of Bologna and IRCCS-S.Orsola University Hospital, Via Massarenti, 9, 40138, Bologna, Italy.
| | - Sean Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | - Marius M Hoeper
- Hannover Medical School and German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | | | | | - Cheryl Lassen
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | | | - Olivier Sitbon
- Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris-Sud, Le Kremlin-Bicêtre, France
- INSERM Unité 999, Le Plessis Robinson, France
| | | | - Kelly M Chin
- University of Texas Southwestern Medical Center, Dallas, USA
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22
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Bergquist CS, Wu X, McLaughlin VV, Rosati CM, Pretorius V, Likosky DS, Haft JW. Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: A STS Database Analysis. Ann Thorac Surg 2021; 114:2157-2162. [PMID: 34838740 DOI: 10.1016/j.athoracsur.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/03/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is optimally treated by pulmonary thromboendarterectomy (PEA). Treatment effectiveness has been evaluated principally using single-center series. Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were used to evaluate a volume-outcomes relationship for PEA. METHODS Circulatory arrest procedures performed between 2012-2018 were identified through an STS-ACSD Participant User File. For descriptive purposes, total center procedural volume categories were computed: low (0-75th percentile, <16); medium (76-95th percentile, 16-100); high (>95th percentile, >100). Mixed effect modeling was used to evaluate the effect of center procedural volume (modeled continuously) on operative mortality, adjusting for preoperative risk factors, with centers as a random effect. RESULTS There were 1,358 cases performed across 64 centers [n/N: low (49/172); medium (12/527); high (3/659)], with 42 centers performing <10 operations during the period. Procedural volume increased 2.6-fold between 2012-2018 (94 versus 339), with 79% of the change in volume accounted for by 4 centers. The mean (IQR) preoperative pulmonary artery systolic value was 74 mmHg (57-88), with no difference (p=0.55) by center volume categories. In unadjusted analysis, patients at high volume centers required fewer transfusions, had shorter ventilator and intensive care unit (ICU) duration, lower frequency of postoperative extracorporeal membrane oxygenation (ECMO), and trended lower mortality (2.1% vs 5.2%, p=0.051). Operative mortality was lower at higher volume centers (ORadjusted,1-case-increase: 0.997; CI95%: 0.994-1.0; p=0.025). CONCLUSIONS Most PEA procedures are performed among a small number of centers, with high-volume hospitals having favorable outcomes. These data suggest a potential role for PEA regionalization.
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Affiliation(s)
- Curtis S Bergquist
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Carlo M Rosati
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Victor Pretorius
- Sulpizio Cardiovascular Center, University of California at San Diego, La Jolla, CA 92037
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109.
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23
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Rosenkranz S, Channick R, Chin KM, Jenner B, Gaine S, Galiè N, Ghofrani HA, Hoeper MM, McLaughlin VV, Du Roure C, Rubin LJ, Sitbon O, Tapson V, Lang IM. The impact of comorbidities on selexipag treatment effect in patients with pulmonary arterial hypertension: insights from the GRIPHON study. Eur J Heart Fail 2021; 24:205-214. [PMID: 34806261 PMCID: PMC9298818 DOI: 10.1002/ejhf.2369] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/23/2021] [Accepted: 10/17/2021] [Indexed: 11/23/2022] Open
Abstract
Aims The number of pulmonary arterial hypertension (PAH) patients with comorbidities is increasing and there are limited data on response to PAH‐targeted therapies in this population. These post hoc analyses explored the effect of selexipag in PAH patients with cardiovascular comorbidities in the GRIPHON study. Methods and results Randomized patients (n = 1156) were classified using three methods: (i) by subgroups defined according to previously published comorbidity count and restrictive haemodynamic criteria: Subgroup A (<3 comorbidities and haemodynamic criteria met; n = 962) and Subgroup B (≥3 comorbidities and/or haemodynamic criteria not met; n = 144); comorbidities included body mass index ≥30 kg/m2, essential hypertension, diabetes, history of coronary artery disease; (ii) by number of comorbidities, with addition of atrial fibrillation (0, 1, 2, 3, 4, or 5); (iii) by presence of individual comorbidities. Selexipag to placebo hazard ratios (HR) and 95% confidence intervals (CI) for morbidity/mortality (primary composite endpoint) were estimated using Cox regression adjusting selexipag effect for baseline covariates. Approximately half of the patients in GRIPHON (n = 584; 50.5%) had comorbidities. Selexipag reduced the risk of a morbidity/mortality event compared with placebo in both Subgroup A (HR 0.66, 95% CI 0.53, 0.82) and Subgroup B (HR 0.50, 95% CI 0.26, 0.96), with no evidence of an inconsistent treatment effect between subgroups (interaction p = 0.432). Consistent results were observed in analyses by number and by specific type of comorbidity. Conclusion Selexipag reduces the risk of a morbidity/mortality event vs. placebo irrespective of patient comorbidity status, suggesting that comorbidity status does not influence the treatment effect of selexipag.
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Affiliation(s)
- Stephan Rosenkranz
- Heart Center, University Hospital Cologne, and Cologne Cardiovascular Research Center (CCRC), Cologne, Germany
| | | | | | | | - Sean Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Nazzareno Galiè
- DIMES, University of Bologna and IRCCS, S. Orsola University Hospital, Bologna, Italy
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research, and Department of Medicine, Imperial College London, London, UK
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | | | | | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | | | - Irene M Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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24
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Frantz RP, Benza RL, Channick RN, Chin K, Howard LS, McLaughlin VV, Sitbon O, Zamanian RT, Hemnes AR, Cravets M, Bruey JM, Roscigno R, Mottola D, Elman E, Zisman LS, Ghofrani HA. TORREY, a Phase 2 study to evaluate the efficacy and safety of inhaled seralutinib for the treatment of pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211057071. [PMID: 34790348 PMCID: PMC8591655 DOI: 10.1177/20458940211057071] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/12/2021] [Indexed: 12/14/2022] Open
Abstract
Aberrant kinase signaling that involves platelet-derived growth factor receptor (PDGFR) α/β, colony stimulating factor 1 receptor (CSF1R), and stem cell factor receptor (c-KIT) pathways may be responsible for vascular remodeling in pulmonary arterial hypertension. Targeting these specific pathways may potentially reverse the pathological inflammation, cellular proliferation, and fibrosis associated with pulmonary arterial hypertension progression. Seralutinib (formerly known as GB002) is a novel, potent, clinical stage inhibitor of PDGFRα/β, CSF1R, and c-KIT delivered via inhalation that is being developed for patients with pulmonary arterial hypertension. Here, we report on an ongoing Phase 2 randomized, double-blind, placebo-controlled trial (NCT04456998) evaluating the efficacy and safety of seralutinib in subjects with World Health Organization Group 1 Pulmonary Hypertension who are classified as Functional Class II or III. A total of 80 subjects will be enrolled and randomized to receive either study drug or placebo for 24 weeks followed by an optional 72-week open-label extension study. The primary endpoint is the change from baseline to Week 24 in pulmonary vascular resistance by right heart catheterization. The secondary endpoint is the change in distance from baseline to Week 24 achieved in the 6-min walk test. A computerized tomography sub-study will examine the effect of seralutinib on pulmonary vascular remodelling. A separate heart rate monitoring sub-study will examine the effect of seralutinib on cardiac effort during the 6-min walk test.
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Affiliation(s)
| | | | | | - Kelly Chin
- UT Southwestern Medical Center, Dallas, TX, USA
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Coghlan GJ, Gaine S, Channick RN, Chin KM, Du Roure C, Gibbs JSR, Hoeper MM, Lang IM, Mathai SC, McLaughlin VV, Mitchell L, Simonneau G, Sitbon O, Tapson V, Galie N. Treatment effect of selexipag on time to disease progression when initiated early in pulmonary arterial hypertension (PAH) patients: GRIPHON and TRITON pooled analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In PAH clinical practice, drugs targeting the prostacyclin pathway, including the oral prostacyclin receptor agonist selexipag, are often initiated years after diagnosis. The GRIPHON (NCT01106014) and TRITON (NCT02558231) randomised controlled trials examined the impact of selexipag on disease progression, primary and secondary endpoints, respectively. In GRIPHON, selexipag significantly reduced the risk of disease progression (composite primary endpoint) in a PAH population (N=1156) with a mean time from diagnosis of 2.4 years, as part of an oral triple, double or monotherapy regimen versus placebo. In TRITON, a potential signal for reduced risk of disease progression was observed with initial triple oral therapy (selexipag, macitentan, tadalafil) versus initial double oral therapy (placebo, macitentan, tadalafil) in a population of 247 newly diagnosed, treatment naïve patients.
Purpose
To investigate the impact of initiating selexipag within 6 months of diagnosis on disease progression in a large PAH population.
Methods
We selected patients from GRIPHON and TRITON diagnosed within 6 months of randomization and compared those on active therapy with selexipag (selexipag group) versus those on control therapy with placebo (control group). Disease progression endpoints were defined as in the GRIPHON and TRITON studies, respectively. Hazard ratios (HR) and 95% CI for time to first disease progression event up to end of double-blind treatment (selexipag/placebo) + 7 days were estimated using a Cox regression model which included treatment as a factor, and baseline prognostic factors and study as covariates.
Results
Overall, 649 patients met the criteria (diagnosis ≤6 months) for these analyses: 329 in the selexipag group (207 from GRIPHON and 122 from TRITON) and 320 in the control group (197 from GRIPHON and 123 from TRITON). Patient characteristics at baseline and treatment regimens were balanced between the treatment groups. With respect to treatment regimen, selexipag/placebo was given as part of triple therapy in 44%, double therapy in 32% and monotherapy in 24% of patients. The median (range) exposure to study treatment was 510 (4–1280) and 409 (3–1318) days in the selexipag and control groups, respectively. There were 67 (20%) and 116 (36%) patients who experienced a disease progression event in the selexipag and control groups, respectively. Selexipag reduced the risk of disease progression (first event) by 52% compared to control (HR 0.48 [95% CI 0.35, 0.66]) (Figure).
Conclusions
This post-hoc pooled analysis of GRIPHON and TRITON patients diagnosed within 6 months suggests that targeting the prostacylin pathway with selexipag within a short time after diagnosis may reduce the risk of disease progression in a broad PAH population.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson
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Affiliation(s)
| | - S Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - R N Channick
- University of California Los Angeles, Los Angeles, United States of America
| | - K M Chin
- University of Texas Southwestern Medical Center, Dallas, United States of America
| | - C Du Roure
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - J S R Gibbs
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - M M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | - I M Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - S C Mathai
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - V V McLaughlin
- University of Michigan, Ann Arbor, United States of America
| | - L Mitchell
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - G Simonneau
- Hôpital Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - O Sitbon
- Hôpital Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - V Tapson
- Cedars-Sinai Medical Center, Los Angeles, United States of America
| | - N Galie
- DIMES, University of Bologna and IRCCS, S.Orsola University Hospital, Bologna, Italy
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26
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Rosenkranz S, Feldman J, McLaughlin VV, Rischard F, Lange TJ, White RJ, Peacock AJ, Gerhardt F, Ebrahimi R, Brooks G, Satler C, Frantz RP. Selonsertib in adults with pulmonary arterial hypertension (ARROW): a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Respir Med 2021; 10:35-46. [PMID: 34425071 DOI: 10.1016/s2213-2600(21)00032-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data obtained in human lung tissue and preclinical models suggest that oxidative stress and increased apoptosis signal-regulating kinase 1 (ASK1) activity might have a prominent role in the pathobiology of pulmonary arterial hypertension (PAH). The purpose of this study was to determine the efficacy, safety, and tolerability of the ASK1 inhibitor selonsertib compared with placebo in patients with PAH. METHODS We did a randomised, double-blind, placebo-controlled, phase 2 trial at 46 centres located in Canada, France, Germany, Italy, the Netherlands, Spain, the UK, and the USA. Participants were aged 18-75 years and had an established diagnosis of idiopathic or hereditary PAH, or PAH associated with connective tissue disease, drugs or toxins, human immunodeficiency virus, or repaired congenital heart defects. Patients were stratified by PAH aetiology and background therapy, and randomly assigned (1:1:1:1) using an interactive voice-response or web-response system to placebo or selonsertib 2 mg, 6 mg, or 18 mg administered orally once daily. Both placebo and selonsertib were in tablet form. The primary efficacy endpoint was change in pulmonary vascular resistance, measured by right heart catheterisation, from baseline to week 24 in the full analysis set. Pair-wise comparisons between each of the selonsertib groups and the placebo group were made with a stratified Wilcoxon (van Elteren) rank sum test for participants without major protocol deviations who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT02234141. FINDINGS Between Dec 3, 2014, and Nov 13, 2015, 151 patients were enrolled and randomly assigned. Of 150 participants who received selonsertib or placebo, 134 (89%) completed 24 weeks of the randomly assigned treatment; all were on background PAH therapy (138 [92%] on combination therapy). 90 (60%) patients were in functional class II and 60 (40%) in functional class III. Mean baseline pulmonary vascular resistance was 772 (SD 334) dyn·s/cm5. Change in pulmonary vascular resistance was 6·0 dyn·s/cm5 (SD 28·0; n=31) for placebo, and 35·0 (35·4) dyn·s/cm5 (n=35; p=0·21 vs placebo) for 2 mg selonsertib, -28·0 (30·2) dyn·s/cm5 (n=34; p=0·27 vs placebo) for 6 mg selonsertib, and -21·0 (37·9) dyn·s/cm5 (n=36; p=0·60 vs placebo) for 18 mg selonsertib. The most frequent adverse events were headache (17 [15%]), abnormal dreams (eight [7%]), nausea (seven [6%]), and diarrhoea (seven [6%]) in the selonsertib groups, and headache (six [16%]), nausea (five [14%]), and diarrhoea (two [5%]) in the placebo group. Serious adverse events occurred in 23 (20%) of 113 selonsertib-treated patients and seven (19%) of 37 patients who received placebo. INTERPRETATION Selonsertib once daily for 24 weeks did not lead to a significant reduction in pulmonary vascular resistance or to clinical improvement in patients with PAH, but appeared to be safe and well tolerated. Although these data do not support the clinical use of selonsertib in PAH, further study of the potential of targeting the ASK1-p38 pathway in PAH is warranted. FUNDING Gilead Sciences.
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Affiliation(s)
- Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University of Cologne, and Cologne Cardiovascular Research Center, University of Cologne, Germany.
| | | | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Tobias J Lange
- Dept of Internal Medicine II, Pulmonology, University Medical Center Regensburg, Germany
| | - R James White
- University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Regional Heart & Lung Centre, Glasgow, UK
| | - Felix Gerhardt
- Department of Cardiology, Heart Center at the University of Cologne, and Cologne Cardiovascular Research Center, University of Cologne, Germany
| | | | | | | | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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27
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Cascino TM, McLaughlin VV. Upfront Combination Therapy for Pulmonary Arterial Hypertension: Time to Be More Ambitious than AMBITION. Am J Respir Crit Care Med 2021; 204:756-759. [PMID: 34402773 PMCID: PMC8528523 DOI: 10.1164/rccm.202107-1625ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Thomas M Cascino
- University of Michigan, 1259, Ann Arbor, Michigan, United States
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28
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Kerr KM, Elliott CG, Chin K, Benza RL, Channick RN, Davis RD, He F, LaCroix A, Madani MM, McLaughlin VV, Park M, Robbins IM, Tapson VF, Terry JR, Test VJ, Jain S, Auger WR. Results From the United States Chronic Thromboembolic Pulmonary Hypertension Registry: Enrollment Characteristics and 1-Year Follow-up. Chest 2021; 160:1822-1831. [PMID: 34090871 PMCID: PMC8628169 DOI: 10.1016/j.chest.2021.05.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 11/09/2022] Open
Abstract
Background The United States Chronic Thromboembolic Pulmonary Hypertension Registry (US-CTEPH-R) was designed to characterize the demographic characteristics, evaluation, clinical course, and outcomes of surgical and nonsurgical therapies for patients with chronic thromboembolic pulmonary hypertension. Research Question What are the differences in baseline characteristics and 1-year outcomes between operated and nonoperated subjects? Study Design and Methods This study describes a multicenter, prospective, longitudinal, observational registry of patients newly diagnosed (< 6 months) with CTEPH. Inclusion criteria required a mean pulmonary artery pressure ≥ 25 mm Hg documented by right heart catheterization and radiologic confirmation of CTEPH. Between 2015 and 2018, a total of 750 patients were enrolled and followed up biannually until 2019. Results Most patients with CTEPH (87.9%) reported a history of acute pulmonary embolism. CTEPH diagnosis delays were frequent (median, 10 months), and most patients reported World Health Organization functional class 3 status at enrollment with a median mean pulmonary artery pressure of 44 mm Hg. The registry cohort was subdivided into Operable patients undergoing pulmonary thromboendarterectomy (PTE) surgery (n = 566), Operable patients who did not undergo surgery (n = 88), and those who were Inoperable (n = 96). Inoperable patients were older than Operated patients; less likely to be obese; have a DVT history, non-type O blood group, or thrombophilia; and more likely to have COPD or a history of cancer. PTE resulted in a median pulmonary vascular resistance decline from 6.9 to 2.6 Wood units (P < .001) with a 3.9% in-hospital mortality. At 1-year follow-up, Operated patients were less likely treated with oxygen, diuretics, or pulmonary hypertension-targeted therapy compared with Inoperable patients. A larger percentage of Operated patients were World Health Organization functional class 1 or 2 at 1 year (82.9%) compared with the Inoperable (48.2%) and Operable/No Surgery (56%) groups (P < .001). Interpretation Differences exist in the clinical characteristics between patients who exhibited operable CTEPH and those who were inoperable, with the most favorable 1-year outcomes in those who underwent PTE surgery. Clinical Trial Registration ClinicalTrials.gov; No.: NCT02429284; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Kim M Kerr
- University of California San Diego, La Jolla, CA.
| | | | - Kelly Chin
- University of Texas Southwestern, Dallas, TX
| | - Raymond L Benza
- The Ohio State University, Columbus, OH; University of California Los Angeles, Los Angeles, CA
| | - Richard N Channick
- The Ohio State University, Columbus, OH; University of California Los Angeles, Los Angeles, CA
| | | | - Feng He
- University of California San Diego, La Jolla, CA
| | | | | | | | - Myung Park
- Virginia Mason Franciscan Health, Tacoma, WA
| | | | | | | | | | - Sonia Jain
- University of California San Diego, La Jolla, CA
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Kerr KM, Elliott CG, Benza RL, Channick RN, Chin KM, Davis RD, Jain S, LaCroix AZ, Madani MM, McLaughlin VV, Park MH, Tapson VF, Auger WR. The United States Chronic Thromboembolic Pulmonary Hypertension Registry: Protocol for a Prospective, Longitudinal Study. JMIR Res Protoc 2021; 10:e25397. [PMID: 33848258 PMCID: PMC8188310 DOI: 10.2196/25397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/24/2021] [Accepted: 04/13/2021] [Indexed: 01/23/2023] Open
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare sequela of acute pulmonary embolism that is treatable when recognized. Awareness of this disease has increased with recent advancements in therapeutic options, but delays in diagnosis remain common, and diagnostic and treatment guidelines are often not followed. Data gathered from international registries have improved our understanding of CTEPH, but these data may not be applicable to the US population owing to differences in demographics and medical practice patterns. Objective The US CTEPH Registry (US-CTEPH-R) was developed to provide essential information to better understand the demographics, risk factors, evaluation, and treatment of CTEPH in the United States, as well as the short- and long-term outcomes of surgical and nonsurgical therapies in the modern treatment era. Methods Thirty sites throughout the United States enrolled 750 subjects in this prospective, longitudinal, observational registry of patients newly diagnosed with CTEPH. Enrollment criteria included a mean pulmonary artery pressure ≥25 mmHg by right heart catheterization and radiologic confirmation of CTEPH by a multidisciplinary adjudication committee. Following enrollment, subjects were followed biannually until the conclusion of the study. Quality of life surveys were administered at enrollment and biannually, and all other testing was at the discretion of the treating clinician. Details regarding surgical therapy, balloon pulmonary angioplasty, and medical therapy were collected at enrollment and at follow-up, as well as information related to health care utilization and survival. Results Data from this registry will improve understanding of the demographics, risk factors, and treatment patterns of patients with CTEPH, and the longitudinal impact of therapies on quality of life, health care utilization, and survival. Conclusions This manuscript details the methodology and design of the first large, prospective, longitudinal registry of patients with CTEPH in the United States. Trial Registration ClinicalTrials.gov NCT02429284; https://www.clinicaltrials.gov/ct2/show/NCT02429284 International Registered Report Identifier (IRRID) DERR1-10.2196/25397
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Affiliation(s)
- Kim M Kerr
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - C Greg Elliott
- Department of Medicine, Intermountain Medical Center, Murray, UT, United States
| | - Raymond L Benza
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, United States
| | - Richard N Channick
- Division of Pulmonary and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Kelly M Chin
- Division of Pulmonary and Critical Care, University of Texas Southwestern, Dallas, TX, United States
| | - R Duane Davis
- Thoracic and Cardiac Surgery, AdventHealth Transplant Institute, Orlando, FL, United States
| | - Sonia Jain
- Division of Biostatistics and Bioinformatics, University of California San Diego, La Jolla, CA, United States
| | - Andrea Z LaCroix
- Division of Epidemiology, University of California San Diego, La Jolla, CA, United States
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, United States
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Myung H Park
- Department of Cardiology, Virginia Mason Franciscan Health, Tacoma, WA, United States
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - William R Auger
- Division of Cardiology, Temple University, Philadelphia, PA, United States
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Hoeper MM, Al-Hiti H, Benza RL, Chang SA, Corris PA, Gibbs JSR, Grünig E, Jansa P, Klinger JR, Langleben D, McLaughlin VV, Meyer GMB, Ota-Arakaki J, Peacock AJ, Pulido T, Rosenkranz S, Vizza CD, Vonk-Noordegraaf A, White RJ, Chang M, Kleinjung F, Meier C, Paraschin K, Ghofrani HA, Simonneau G. Switching to riociguat versus maintenance therapy with phosphodiesterase-5 inhibitors in patients with pulmonary arterial hypertension (REPLACE): a multicentre, open-label, randomised controlled trial. Lancet Respir Med 2021; 9:573-584. [PMID: 33773120 DOI: 10.1016/s2213-2600(20)30532-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Riociguat and phosphodiesterase-5 inhibitors (PDE5i), approved for the treatment of pulmonary arterial hypertension (PAH), act on the same pathway via different mechanisms. Riociguat might be an alternative option for patients with PAH who do not respond sufficiently to treatment with PDE5i, but comparisons of the potential benefits of riociguat and PDE5i in these patients are needed. The aim of this trial was to assess the effects of switching to riociguat from PDE5i therapy versus continued PDE5i therapy in patients with PAH at intermediate risk of 1-year mortality. METHODS Riociguat rEplacing PDE5i therapy evaLuated Against Continued PDE5i thErapy (REPLACE) was an open-label, randomised controlled trial in 81 hospital-based pulmonary hypertension centres in 22 countries. The study enrolled patients aged 18-75 years with symptomatic PAH at intermediate risk of 1-year mortality (based on the European Society for Cardiology-European Respiratory Society guideline thresholds for WHO functional class and 6-min walk distance [6MWD]) who were receiving treatment with a PDE5i with or without an endothelin receptor antagonist for at least 6 weeks before randomisation. Patients were excluded if they had been previously treated with riociguat, had used prostacyclin analogues or prostacyclin receptor agonists within 30 days before randomisation, had clinically significant restrictive or obstructive parenchymal lung disease, or had left heart disease. Patients were randomly assigned (1:1) to remain on PDE5i treatment (oral sildenafil [≥60 mg per day] or oral tadalafil [20-40 mg per day]; the PDE5i group) or to switch to oral riociguat (up to 2·5 mg three times per day; the riociguat group), using an interactive voice and web response system, stratified by cause of PAH. The primary endpoint was clinical improvement by week 24, defined as an absence of clinical worsening and prespecified improvements in at least two of three variables (6MWD, WHO functional class, and N-terminal prohormone of brain natriuretic peptide), analysed using last observation carried forward in all randomly assigned patients with observed values at baseline and week 24 who received at least one dose of study medication (the full analysis set). Secondary endpoints included clinical worsening events. The trial has been completed and is registered with ClinicalTrials.gov, NCT02891850. FINDINGS Between Jan 11, 2017, and July 31, 2019, 293 patients were screened, of which 226 patients were randomly assigned to the riociguat group (n=111) or to the PDE5i group (n=115). 211 patients completed the study and 14 patients discontinued (seven in each group). One patient assigned to the PDE5i group did not receive treatment, so 225 patients were included in the safety analysis, and one further patient in the PDE5i group had missing components of the composite primary endpoint at baseline, so 224 patients were included in the full analysis set. The primary endpoint was met by 45 (41%) of 111 patients in the riociguat group and 23 (20%) of 113 patients in the PDE5i group; odds ratio [OR] 2·78 (95% CI 1·53-5·06; p=0·0007). Clinical worsening events occurred in one (1%) of 111 patients in the riociguat group (hospitalisation due to worsening PAH) and 10 (9%) of 114 patients in the PDE5i group (hospitalisation due to worsening PAH [n=9]; disease progression [n=1]; OR 0·10 [0·01-0·73]; p=0·0047). The most frequently occurring adverse events were hypotension (15 [14%]), headache (14 [13%]), and dyspepsia (10 [9%]) in the riociguat group, and headache (eight [7%]), cough (seven [6%]), and upper respiratory tract infection (seven [6%]) in the PDE5i group. Serious adverse events were reported in eight (7%) of 111 patients in the riociguat group and 19 (17%) of 114 patients in the PDE5i group. During the study, four patients died in the PDE5i group, one of them during the safety follow-up period. INTERPRETATION Switching to riociguat from PDE5i treatment, both of which act via the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate pathway, could be a strategic option for treatment escalation in patients with PAH at intermediate risk of 1-year mortality. FUNDING Bayer AG, Merck Sharp & Dohme.
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Affiliation(s)
- Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, member of the German Center for Lung Research (DZL), Hannover, Germany.
| | - Hikmet Al-Hiti
- Department of Cardiology, Institute of Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Raymond L Benza
- Division of Cardiovascular Diseases, Ohio State University, Columbus, OH, USA
| | - Sung-A Chang
- Division of Cardiology, Department of Medicine, Heart Vascular and Stroke Institute Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Paul A Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - J Simon R Gibbs
- National Heart and Lung Institute, Imperial College London, and Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center (TLRC), member of DZL, Heidelberg, Germany
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - James R Klinger
- Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Gisela M B Meyer
- Centro de Hipertensão Pulmonar, Complexo Hospitalar Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Jaquelina Ota-Arakaki
- Pulmonary Circulation Group, Department of Medicine, Universidade Federal de São Paulo-Hospital São Paulo, São Paulo, Brazil
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Regional Lung and Heart Centre, Glasgow, UK
| | - Tomás Pulido
- Cardiopulmonary Department, National Heart Institute, Mexico City, Mexico
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology), Cologne Cardiovascular Research Center (CCRC), and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Carmine Dario Vizza
- Pulmonary Hypertension Unit, Department of Cardiovascular and Respiratory Disease, La Sapienza University of Rome, Rome, Italy
| | | | - R James White
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | | | - Hossein Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, member of DZL, Giessen, Germany; Department of Pneumology, Kerchoff Clinic, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and Inserm U999, Le Kremlin-Bicêtre, France
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Gaine S, Sitbon O, Channick RN, Chin KM, Sauter R, Galiè N, Hoeper MM, McLaughlin VV, Preiss R, Rubin LJ, Simonneau G, Tapson V, Ghofrani HA, Lang I. Relationship Between Time From Diagnosis and Morbidity/Mortality in Pulmonary Arterial Hypertension: Results From the Phase III GRIPHON Study. Chest 2021; 160:277-286. [PMID: 33545163 DOI: 10.1016/j.chest.2021.01.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Early initiation of pulmonary arterial hypertension (PAH) therapies is associated with improved long-term outcomes, yet data on the early use of prostacyclin pathway agents are limited. In these post hoc analyses of the Prostacyclin (PGI2) Receptor Agonist In Pulmonary Arterial Hypertension (GRIPHON) study, the largest randomized controlled trial for PAH to date, the prognostic value of time from diagnosis and its impact on treatment response were examined. RESEARCH QUESTION How does time from diagnosis impact morbidity/mortality events and response to selexipag treatment in patients with PAH? STUDY DESIGN AND METHODS The GRIPHON study randomly assigned 1,156 patients with PAH to selexipag or placebo treatment. Patients were categorized post hoc into a time from diagnosis of ≤ 6 months and > 6 months at randomization. Hazard ratios (selexipag vs placebo) were calculated for the primary end point of morbidity/mortality by time from diagnosis using Cox proportional hazard models. RESULTS Time from diagnosis was ≤ 6 months in 34.9% and > 6 months in 65.1% of patients. Time from diagnosis was prognostic of morbidity/mortality, with newly diagnosed patients having a poorer long-term outcome than patients diagnosed for longer. Compared with placebo, selexipag reduced the risk of morbidity/mortality in patients with a time from diagnosis of ≤ 6 months and > 6 months, with a more pronounced effect in newly diagnosed patients (hazard ratio, 0.45 [95% CI, 0.33-0.63] and 0.74 [95% CI, 0.57-0.96], respectively; P = .0219 for interaction). INTERPRETATION In the GRIPHON study, newly diagnosed PAH patients had a worse prognosis than patients with a longer time from diagnosis. The benefit of selexipag treatment on disease progression was more pronounced in patients treated earlier than in patients treated later. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01106014; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | | | | | - Rafael Sauter
- Actelion Pharmaceuticals, Ltd., Allschwil, Switzerland
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Ralph Preiss
- Actelion Pharmaceuticals, Ltd., Allschwil, Switzerland
| | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA
| | - Gérald Simonneau
- Hôpital Universitaire de Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | | | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany; member of the German Center for Lung Research, and Department of Medicine, Imperial College London, London, UK
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
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Cascino TM, Ashur C, Richardson CR, Jackson EA, McLaughlin VV. Impact of patient characteristics and perceived barriers on referral to exercise rehabilitation among patients with pulmonary hypertension in the United States. Pulm Circ 2020; 10:2045894020974926. [PMID: 33343883 PMCID: PMC7731716 DOI: 10.1177/2045894020974926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/30/2020] [Indexed: 11/23/2022] Open
Abstract
Exercise rehabilitation is underutilized in patients with pulmonary arterial hypertension despite improving exercise capacity and quality of life. We sought to understand the association between (1) patient characteristics and (2) patient-perceived barriers and referral to exercise rehabilitation. We performed a cross-sectional survey of patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension attending an International PAH meeting. Predictors of referral considered included gender, body mass index, subjective socioeconomic status, insurance type, age, and World Health Organization functional class and perceived barriers assessed using the Cardiac Rehabilitation Barriers Scale. Among 65 participants, those in the lowest subjective socioeconomic status tertile had reduced odds of referral compared to the highest tertile participants (odds ratio 0.22, 95% confidence interval: 0.05–0.98, p = 0.047). Several patient-perceived barriers were associated with reduced odds of referral. For every 1-unit increase in a reported barrier on a five-point Likert scale, odds of referral were reduced by 85% for my doctor did not feel it was necessary; 85% for prefer to take care of my health alone, not in a group; 78% many people with heart and lung problems don’t go, and they are fine; and 78% for I didn’t know about exercise therapy. The lack of perceived need subscale and overall barriers score were associated with a 92% and 77% reduced odds of referral, respectively. These data suggest the need to explore interventions to promote referral among low socioeconomic status patients and address perceived need for the therapy.
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Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carmel Ashur
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Elizabeth A Jackson
- Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Simonneau G, Ghofrani HA, Corris PA, Rosenkranz S, Grünig E, White J, McLaughlin VV, Langleben D, Meier C, Busse D, Kleinjung F, Benza RL. Assessment of the REPLACE study composite endpoint in riociguat-treated patients in the PATENT study. Pulm Circ 2020; 10:2045894020973124. [PMID: 33354316 PMCID: PMC7734510 DOI: 10.1177/2045894020973124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/22/2020] [Indexed: 11/25/2022] Open
Abstract
The goal of treatment in patients with pulmonary arterial hypertension is to achieve a low risk status, indicating a favorable long-term outcome. The REPLACE study investigated the efficacy of switching to riociguat in patients with pulmonary arterial hypertension and an insufficient response to phosphodiesterase-5 inhibitors. In this post hoc analysis, we applied the REPLACE composite endpoint of clinical improvement to the placebo-controlled PATENT-1 study of riociguat in pulmonary arterial hypertension and its long-term extension, PATENT-2. Clinical improvement was defined as ≥2 of the following in patients who completed the study without clinical worsening: ≥10% or ≥30 m improvement in 6-minute walking distance; World Health Organization functional class I or II; ≥30% decrease in N-terminal prohormone of brain natriuretic peptide. At PATENT-1 Week 12, patients treated with riociguat were more likely to achieve the composite endpoint vs. placebo (P < 0.0001), with similar results in pretreated (P = 0.0189) and treatment-naïve (P < 0.0001) patients. Achievement of the composite endpoint at Week 12 was associated with a 45% reduction in relative risk of death and a 19% reduction in relative risk of clinical worsening in PATENT-2. Overall, these data suggest that use of the REPLACE composite endpoint in patients with pulmonary arterial hypertension is a valid assessment of response to treatment.
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Affiliation(s)
- Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and INSERM Unité 999, Le Kremlin-Bicêtre, France
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany, Department of Pneumology, Kerchoff Clinic, Bad Nauheim, Germany and Department of Medicine, Imperial College London, London, UK
| | - Paul A Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stephan Rosenkranz
- Department III of Internal Medicine, Cologne University Heart Center, Cologne, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension at Thoraxklinik Heidelberg, Heidelberg, Germany
| | - Jim White
- Division of Pulmonary and Critical Care Medicine and the Mary M. Parkes Center, University of Rochester Medical Center, Rochester, NY, USA
| | | | - David Langleben
- Center for Pulmonary Vascular Disease and Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
| | | | | | | | - Raymond L Benza
- Department of Medicine, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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Sitbon O, Chin KM, Channick RN, Benza RL, Di Scala L, Gaine S, Ghofrani HA, Lang IM, McLaughlin VV, Preiss R, Rubin LJ, Simonneau G, Tapson VF, Galiè N, Hoeper MM. Risk assessment in pulmonary arterial hypertension: Insights from the GRIPHON study. J Heart Lung Transplant 2020; 39:300-309. [PMID: 32061506 DOI: 10.1016/j.healun.2019.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/26/2019] [Accepted: 12/29/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Approaches to risk assessment in pulmonary arterial hypertension (PAH) include the noninvasive French risk assessment approach (number of low-risk criteria based on the European Society of Cardiology and European Respiratory Society guidelines) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) 2.0 risk calculator. The prognostic and predictive value of these methods for morbidity/mortality was evaluated in the predominantly prevalent population of GRIPHON, the largest randomized controlled trial in PAH. METHODS GRIPHON randomized 1,156 patients with PAH to selexipag or placebo. Post-hoc analyses were performed on the primary composite end-point of morbidity/mortality by the number of low-risk criteria (World Health Organization functional class I-II; 6-minute walk distance >440 m; N-terminal pro-brain natriuretic peptide <300 ng/liter) and REVEAL 2.0 risk category. Hazard ratios and 95% confidence intervals were calculated using Cox proportional hazard models. RESULTS Both the number of low-risk criteria and the REVEAL 2.0 risk category were prognostic for morbidity/mortality at baseline and any time-point during the study. Patients with 3 low-risk criteria at baseline had a 94% reduced risk of morbidity/mortality compared to patients with 0 low-risk criteria and were all categorized as low-risk by REVEAL 2.0. The treatment effect of selexipag on morbidity/mortality was consistent irrespective of the number of low-risk criteria or the REVEAL 2.0 risk category at any time-point during the study. Selexipag-treated patients were more likely to increase their number of low-risk criteria from baseline to week 26 than placebo-treated patients (odds ratio 1.69, p = 0.0002); similar results were observed for REVEAL 2.0 risk score. CONCLUSIONS These results support the association between risk profile and long-term outcome and suggest that selexipag treatment may improve risk profile.
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Affiliation(s)
- Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France.
| | | | | | | | | | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, member of the German Center of Lung Research, Giessen, Germany; Department of Medicine, Imperial College London, London, United Kingdom
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | - Vallerie V McLaughlin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ralph Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, California
| | - Gérald Simonneau
- Hôpital Universitaire de Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France
| | | | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Center of Lung Research, Hannover Medical School, Hannover, Germany
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Chin KM, Rubin LJ, Channick R, Di Scala L, Gaine S, Galiè N, Ghofrani HA, Hoeper MM, Lang IM, McLaughlin VV, Preiss R, Simonneau G, Sitbon O, Tapson VF. Association of N-Terminal Pro Brain Natriuretic Peptide and Long-Term Outcome in Patients With Pulmonary Arterial Hypertension. Circulation 2020; 139:2440-2450. [PMID: 30982349 PMCID: PMC6530970 DOI: 10.1161/circulationaha.118.039360] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND NT-proBNP (N-terminal pro brain natriuretic peptide) levels are included in the multiparametric risk assessment approach for pulmonary arterial hypertension (PAH) outlined in PAH guidelines. However, data supporting the use of NT-proBNP risk thresholds in assessing prognosis in PAH are limited. The GRIPHON trial (Prostacyclin [PGI2] Receptor Agonist In Pulmonary Arterial Hypertension) provides an opportunity to assess the prognostic value of NT-proBNP thresholds in a controlled clinical trial and to evaluate the response to selexipag according to these thresholds. METHODS The event-driven GRIPHON trial randomly assigned patients to selexipag or placebo. NT-proBNP was measured at regular intervals in GRIPHON. Here, patients were categorized post hoc into low, medium, and high NT-proBNP subgroups according to 2 independent sets of thresholds: (1) baseline tertiles: <271 ng/L; 271 to 1165 ng/L; >1165 ng/L; and (2) 2015 European Society of Cardiology/European Respiratory Society guidelines cutoffs: <300 ng/L; 300 to 1400 ng/L; >1400 ng/L. Hazard ratios (selexipag versus placebo) with 95% CIs were calculated for the primary end point (composite morbidity/mortality events) by NT-proBNP category at baseline using Cox proportional-hazards models, and at any time during the exposure period using a time-dependent Cox model. RESULTS With both thresholds, baseline and follow-up NT-proBNP categories were highly prognostic for future morbidity/mortality events during the study ( P<0.0001). In the time-dependent analysis, the risk of experiencing a morbidity/mortality event was 92% and 83% lower in selexipag-treated patients with a low and medium NT-proBNP level, and 90% and 56% lower in placebo-treated patients with a low and medium NT-proBNP level, in comparison with patients with a high NT-proBNP level. Selexipag reduced the risk of morbidity/mortality events across all 3 NT-proBNP categories in both the baseline and time-dependent analyses, with a more pronounced treatment benefit of selexipag seen in the medium and low NT-proBNP subgroups (interaction P values 0.20 and 0.007 in the baseline and time-dependent analyses). CONCLUSIONS These analyses further establish the prognostic relevance of NT-proBNP levels in PAH and provide first evidence for the association of NT-proBNP level and treatment response. Using 2 similar sets of thresholds, these analyses support the relevance of the low, medium, and high NT-proBNP categories as part of the multiparametric risk assessment approach outlined in the European Society of Cardiology/European Respiratory Society guidelines for the management of PAH patients. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01106014.
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Affiliation(s)
- Kelly M Chin
- Division of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (K.M.C.)
| | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego (L.J.R.)
| | - Richard Channick
- David Geffen School of Medicine, University of California Los Angeles (R.C.)
| | - Lilla Di Scala
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland (L.D.S., R.P.)
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland (S.G.)
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic, and Specialty Medicine - DIMES, University of Bologna, Italy (N.G.)
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center of Lung Research, and Department of Medicine, Imperial College London, London, UK (H.-A.G.)
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center of Lung Research, Hannover (M.M.H.)
| | - Irene M Lang
- Medical University of Vienna, Department of Internal Medicine II, Division of Cardiology, Allgemeines Krankenhaus, Austria (I.M.L.)
| | - Vallerie V McLaughlin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (V.V.M.)
| | - Ralph Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland (L.D.S., R.P.)
| | - Gérald Simonneau
- APHP Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs, CHU Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France (G.S., O.S.)
| | - Olivier Sitbon
- APHP Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs, CHU Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France (G.S., O.S.)
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (V.F.T.)
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Sanderson R, Kolias TJ, McLaughlin VV, Khanna D, Visovatti S. LEFT ATRIAL AND LEFT VENTRICULAR STRAIN DURING EXERCISE UNMASK DIASTOLIC DYSFUNCTION IN SCLERODERMA. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32372-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rajagopal S, Channick R, Chin K, Kim NH, Flynn M, Leroy S, Ong R, Wetherill G, McLaughlin VV. COMORBIDITIES IN PULMONARY ARTERIAL HYPERTENSION (PAH): INSIGHTS FROM THE REAL-WORLD OPSUMIT® USERS (OPUS) REGISTRY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32728-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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McLaughlin VV, Channick R, De Marco T, Farber HW, Gaine S, Galié N, Krasuski RA, Preston I, Souza R, Coghlan JG, Frantz RP, Hemnes A, Kim NH, Lang IM, Langleben D, Li M, Sitbon O, Tapson V, Frost A. Results of an Expert Consensus Survey on the Treatment of Pulmonary Arterial Hypertension With Oral Prostacyclin Pathway Agents. Chest 2019; 157:955-965. [PMID: 31738929 DOI: 10.1016/j.chest.2019.10.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/11/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Treatment of pulmonary arterial hypertension (PAH) has evolved substantially over the past two decades and varies according to etiology, functional class (FC), hemodynamic parameters, and other clinical factors. Current guidelines do not provide definitive recommendations regarding the use of oral prostacyclin pathway agents (PPAs) in PAH. To provide guidance on the use of these agents, an expert panel was convened to develop consensus statements for the initiation of oral PPAs in adults with PAH. METHODS A systematic literature search was conducted using MEDLINE. The established RAND/University of California Los Angeles appropriateness method, which incorporates the Delphi method and the nominal group technique, was used to create consensus statements. Idiopathic, heritable, repaired congenital heart defect, and drug- or toxin-induced PAH (IPAH+) was considered as one etiologic grouping. The process was focused on the use of oral treprostinil or selexipag in patients with IPAH+ or connective tissue disease-associated PAH and FC II or III symptoms receiving background dual endothelin receptor antagonist/phosphodiesterase type 5 inhibitor therapy. RESULTS The panel developed 14 consensus statements regarding the appropriate use of oral PPAs in the target population. The panel identified 13 clinical scenarios in which selexipag may be considered as a treatment option. CONCLUSIONS The paucity of clinical evidence overall, and particularly from randomized trials in this setting, creates a gap in knowledge. These consensus statements are intended to aid physicians in navigating treatment options and using oral PPAs in the most appropriate manner in patients with PAH.
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Affiliation(s)
| | - Richard Channick
- Department of Medicine, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Teresa De Marco
- Department of Cardiology, University of California, San Francisco, CA
| | - Harrison W Farber
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | | | - Nazzareno Galié
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | | | - Ioana Preston
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Rogerio Souza
- Pulmonary Department, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - J Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London, England
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Anna Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nick H Kim
- Department of Cardiothoracic Surgery, University of California San Diego Medical Center, San Diego, CA
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | - David Langleben
- Center for Pulmonary Vascular Disease, Cardiology Division, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Olivier Sitbon
- Université Paris-Saclay, APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France
| | - Victor Tapson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Adaani Frost
- Department of Medicine, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX
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Rosenkranz S, Channick R, Chin K, Jenner B, Gaine S, Galie N, Ghofrani HA, Hoeper MM, McLaughlin VV, Preiss R, Rubin LJ, Simonneau G, Sitbon O, Tapson V, Lang IM. 4973Efficacy and safety of selexipag in pulmonary arterial hypertension (PAH) patients with and without significant cardiovascular (CV) comorbidities. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Many PAH patients today have a number of CV comorbidities, yet data on the efficacy and safety of therapies in such patients remain scarce. Most recent PAH clinical trials also include patients with comorbidities.
Purpose
To assess the long-term efficacy and safety of the oral, selective IP prostacyclin receptor agonist, selexipag, in PAH patients with and without significant CV comorbidities using post hoc analysis of GRIPHON data.
Methods
GRIPHON enrolled 1156 PAH patients randomised 1:1 to placebo:selexipag. The present analysis includes patients with right heart catheterisation within 1 year of randomisation who were categorised as with or without CV comorbidities. Patients with CV comorbidities were defined as having ≥3 of the following: body mass index (BMI) >30 kg/m2, history of essential hypertension, diabetes mellitus, or historical evidence of significant coronary artery disease; if PAWP/LVEDP was >12 but <15 mmHg, pulmonary vascular resistance (PVR) had to be >500 dyn.sec/cm5; if PAWP/LVEDP was <12, then PVR had to be >300 dyn.sec/cm5. Selexipag effect on time to first morbidity/mortality (M/M) event up to end of treatment was assessed for both subgroups. Baseline (BL) adjusted treatment hazard ratios with 95% CIs were calculated using Cox models. Model building involved stepwise backward elimination of BL covariates.
Results
752 PAH patients could be categorised based on these criteria (99 with CV comorbidities, 653 without). At BL, patients with CV comorbidities were older (median [range] 60 [28–80] vs 46 [18–78] yrs), had higher BMI (mean [SD] 33.3 [7.23] vs 26.0 [5.64] kg/m2) and lower 6-minute walk distance (mean [SD] 319 [95.7] vs 354 [79.3] m) vs those without. A greater proportion were from Western Europe/Australia/North America (60.6% vs 38.9%) and in WHO functional class III (69.7% vs 49.9%). At BL, 82.8% of patients with CV comorbidities were receiving PAH therapies vs 75.7% of those without. As expected, at BL a higher proportion of patients with CV comorbidities (vs without) had previous/concomitant cardiac disease (62.6% vs 43.0%), metabolism/nutrition disorders (75.8% vs 31.2%), respiratory/thoracic/mediastinal disorders (59.6% vs 37.5%) and vascular disorders (76.8% vs 37.4%). Selexipag reduced the risk of M/M events vs placebo in both subgroups (Figure), with no evidence of an inconsistent treatment effect (interaction p-value=0.1544). Adverse events leading to treatment discontinuation were reported in 35.4% (25.9% selexipag, 46.7% placebo) of patients with CV comorbidities and 35.0% (32.0% selexipag, 38.0% placebo) of those without. Common prostacyclin associated side effects observed with selexipag (headache, diarrhoea, nausea) were reported at a similar incidence in both subgroups.
Conclusions
Selexipag had a beneficial effect on long-term outcome in PAH patients both with and without CV comorbidities. Safety in both groups was consistent with the known profile of selexipag.
Acknowledgement/Funding
Actelion Pharmaceuticals Ltd
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Affiliation(s)
| | - R Channick
- University of California Los Angeles, Los Angeles, United States of America
| | - K Chin
- UT Southwestern Medical Centre, Dallas, United States of America
| | - B Jenner
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - S Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - N Galie
- University of Bologna, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Bologna, Italy
| | - H A Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research, and Department of Medicine, Imperial College London, London, United Kingdom
| | - M M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | - V V McLaughlin
- University of Michigan, Ann Arbor, United States of America
| | - R Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - L J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, United States of America
| | - G Simonneau
- Hopital Universitaire de Bicetre, Universite Paris-Sud, Le Kremlin Bicetre, France
| | - O Sitbon
- Hopital Universitaire de Bicetre, Universite Paris-Sud, Le Kremlin Bicetre, France
| | - V Tapson
- Cedars-Sinai Medical Center, Los Angeles, United States of America
| | - I M Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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White RJ, Vonk-Noordegraaf A, Rosenkranz S, Oudiz RJ, McLaughlin VV, Hoeper MM, Grünig E, Ghofrani HA, Chakinala MM, Barberà JA, Blair C, Langley J, Frost AE. Clinical outcomes stratified by baseline functional class after initial combination therapy for pulmonary arterial hypertension. Respir Res 2019; 20:208. [PMID: 31511080 PMCID: PMC6739949 DOI: 10.1186/s12931-019-1180-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 09/03/2019] [Indexed: 11/16/2022] Open
Abstract
Background Initial combination therapy with ambrisentan and tadalafil reduced the risk of clinical failure events for treatment-naïve participants with pulmonary arterial hypertension (PAH) as compared to monotherapy. Previous studies in PAH have demonstrated greater treatment benefits in more symptomatic participants. Methods AMBITION was an event-driven, double-blind study in which participants were randomized 2:1:1 to once-daily initial combination therapy with ambrisentan 10 mg plus tadalafil 40 mg, ambrisentan 10 mg plus placebo, or tadalafil 40 mg plus placebo. In this pre-specified subgroup analysis, we compared the efficacy data between those with functional class (FC) II vs. FC III symptoms at baseline. Results This analysis included 500 participants in the previously defined primary analysis set (n = 155 FC II, n = 345 FC III). Comparing combination therapy to pooled monotherapy, the risk of clinical failure events was reduced by 79% (hazard ratio, 0.21 [95% confidence interval: 0.071, 0.63]) for FC II patients and 42% (hazard ratio, 0.58 [95% confidence interval: 0.39, 0.86]) for FC III patients. In a post-hoc analysis, the risk of first hospitalization for worsening PAH was also reduced by combination therapy, particularly for FC II patients (0 combination vs. 11 [14%] pooled monotherapy). Adverse events were frequent but comparable between the subgroups. Conclusions Treatment benefit from initial combination therapy appeared at least as great for FC II as for FC III participants. Hospitalizations for worsening PAH were not observed in FC II participants assigned to combination. The present data support an initial combination strategy for newly diagnosed patients even when symptoms are less severe. Funded by Gilead Sciences, Inc. and GlaxoSmithKline; AMBITION ClinicalTrials.gov number, NCT01178073. Supplementary information Supplementary information accompanies this paper at 10.1186/s12931-019-1180-1.
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Affiliation(s)
- R James White
- Division of Pulmonary & Critical Care Medicine, University of Rochester Medical Center, 400 Red Creek Dr, Rochester, NY, 14623, USA.
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Medicine and Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Cologne, Germany
| | - Ronald J Oudiz
- Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, German Center for Lung Research (DZL), Hanover, Germany
| | - Ekkehard Grünig
- Centre for pulmonary hypertension, German Center for Lung Research (DZL), Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Hossein-Ardeschir Ghofrani
- German Center for Lung Research (DZL), Kerckhoff Clinic, Department of Pulmonology, Universities of Giessen and Marburg Lung Center (UGMLC), Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Murali M Chakinala
- Division of Pulmonary & Critical Care Medicine, Washington University, St. Louis, MO, USA
| | - Joan A Barberà
- Department of Pulmonary Medicine, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | | | | | - Adaani E Frost
- Houston Methodist Hospital, Institute for Academic Medicine, Houston, TX, USA
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McLaughlin VV, Hoeper MM, Channick RN, Chin KM, Delcroix M, Gaine S, Ghofrani HA, Jansa P, Lang IM, Mehta S, Pulido T, Sastry BKS, Simonneau G, Sitbon O, Souza R, Torbicki A, Tapson VF, Perchenet L, Preiss R, Verweij P, Rubin LJ, Galiè N. Pulmonary Arterial Hypertension-Related Morbidity Is Prognostic for Mortality. J Am Coll Cardiol 2019; 71:752-763. [PMID: 29447737 DOI: 10.1016/j.jacc.2017.12.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/24/2017] [Accepted: 12/06/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Registry data suggest that disease progression in pulmonary arterial hypertension (PAH) is indicative of poor prognosis. However, the prognostic relevance of PAH-related morbidity has not been formally evaluated in randomized controlled trials. OBJECTIVES The purpose of these analyses was to assess the impact of morbidity events on the risk of subsequent mortality using the landmark method and data from the SERAPHIN and GRIPHON studies. METHODS For each study, the risk of all-cause death up to the end of the study was assessed from the landmark time point (months 3, 6, and 12) according to whether a patient had experienced a primary endpoint morbidity event before the landmark. Each analysis was conducted using data from all patients who were available for survival follow-up at the landmark. RESULTS In the SERAPHIN study, on the basis of the 3-month landmark time point, patients who experienced a morbidity event before month 3 had an increased risk of death compared with patients who did not (hazard ratio [HR]: 3.39; 95% confidence interval [CI]: 1.94 to 5.92). In the GRIPHON study, on the basis of the 3-month landmark time point, there was also an increased risk with a HR of 4.48; (95% CI: 2.98 to 6.73). Analyses based on 6-month and 12-month landmarks also showed increased risk in patients who experienced morbidity events, albeit with a reduced HR. CONCLUSIONS These results demonstrate the prognostic relevance of PAH-related morbidity as defined in the SERAPHIN and GRIPHON studies, highlighting the importance of preventing disease progression in patients with PAH and supporting the clinical relevance of SERAPHIN and GRIPHON morbidity events. (Study of Macitentan [ACT-064992] on Morbidity and Mortality in Patients With Symptomatic Pulmonary Arterial Hypertension [SERAPHIN]; NCT00660179; Selexipag [ACT-293987] in Pulmonary Arterial Hypertension [GRIPHON]; NCT01106014).
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Affiliation(s)
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research, Hannover, Germany
| | - Richard N Channick
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany; Department of Medicine, Imperial College London, London, United Kingdom
| | | | - Irene M Lang
- Medical University of Vienna, Department of Internal Medicine II, Division of Cardiology, Allgemeines Krankenhaus, Vienna, Austria
| | - Sanjay Mehta
- Respirology Division, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Tomás Pulido
- Cardiopulmonary Department, Ignacio Chávez National Heart Institute, Mexico City, Mexico
| | | | | | | | - Rogério Souza
- INCOR Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Adam Torbicki
- Medical Centre for Postgraduate Education, CMKP European Health Centre, Otwock, Poland
| | | | | | - Ralph Preiss
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego Medical School, La Jolla, California
| | - Nazzareno Galiè
- Istituto di Malattie dell'Apparato Cardiovascolare, Università di Bologna, Bologna, Italy
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Cascino TM, McLaughlin VV, Richardson CR, Behbahani-Nejad N, Moles VM, Visovatti SH, Jackson EA. Physical activity and quality of life in patients with pulmonary hypertension. Eur Respir J 2019; 53:13993003.00028-2019. [PMID: 30880287 DOI: 10.1183/13993003.00028-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/06/2019] [Indexed: 01/16/2023]
Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Victor M Moles
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott H Visovatti
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth A Jackson
- Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Cascino TM, McLaughlin VV, Richardson CR, Behbahani-Nejad N, Moles VM, Visovatti SH, Jackson EA. Barriers to physical activity in patients with pulmonary hypertension. Pulm Circ 2019; 9:2045894019847895. [PMID: 30983524 PMCID: PMC6540505 DOI: 10.1177/2045894019847895] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) have low levels of physical activity (PA). Increased PA has health benefits including improved quality of life. This study aimed to identify patient-perceived barriers to PA that correlate with objectively measured PA in this population. We performed a cross-sectional survey of 40 patients with PAH and CTEPH. Participants rated how often 15 barriers interfere with being physically active on a 5-point Likert Scale. The primary outcome measure was PA quantified using the Fitbit Zip activity tracker for two weeks. The primary independent variables were the 15 barriers and a summary score (total average barriers). Separate multivariable linear regressions were performed to assess the association between the 15 barriers and the summary score and PA adjusting for age, sex, and PAH etiology. Of the participants, 85% (34/40) had valid step counts and were included. Of these 34, 85% (n = 29) were female and 91% (n = 31) had PAH. The median (interquartile range [IQR]) number of daily steps was 3913 (2309-6313). The barriers endorsed most strongly were lack of self-discipline, lack of energy, and lack of interest. In the multivariable analysis, a 1-unit increase in perceived lack of interest, lack of enjoyment, and lack of skills was associated with a significant decrease in step counts of -1414 steps (95% confidence interval [CI] = (-2580 - -248), -1458 steps (-2404 - -511), and -1533 steps (-2910 - -156), respectively. Counseling and interventions aimed at increasing PA in patients with PAH should address interest, enjoyment, and skill development.
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Affiliation(s)
- Thomas M Cascino
- 1 Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Victor M Moles
- 1 Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott H Visovatti
- 1 Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth A Jackson
- 4 Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Humbert M, Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An insider view on the World Symposium on Pulmonary Hypertension. Lancet Respir Med 2019; 7:484-485. [PMID: 30956061 DOI: 10.1016/s2213-2600(19)30111-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marc Humbert
- Service de Pneumologie et Soins Intensifs, CHU de Bicêtre, F-94275, Le Kremlin-Bicêtre, France.
| | - Nazzareno Galiè
- Service de Pneumologie et Soins Intensifs, CHU de Bicêtre, F-94275, Le Kremlin-Bicêtre, France
| | - Vallerie V McLaughlin
- Service de Pneumologie et Soins Intensifs, CHU de Bicêtre, F-94275, Le Kremlin-Bicêtre, France
| | - Lewis J Rubin
- Service de Pneumologie et Soins Intensifs, CHU de Bicêtre, F-94275, Le Kremlin-Bicêtre, France
| | - Gérald Simonneau
- Service de Pneumologie et Soins Intensifs, CHU de Bicêtre, F-94275, Le Kremlin-Bicêtre, France
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Benza RL, Corris PA, Ghofrani HA, Kanwar M, McLaughlin VV, Raina A, Simonneau G. EXPRESS: Switching to riociguat: A potential treatment strategy for the management of CTEPH and PAH. Pulm Circ 2019; 10:2045894019837849. [PMID: 30803329 PMCID: PMC7074518 DOI: 10.1177/2045894019837849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
Currently, five classes of drug are approved for the treatment of pulmonary arterial hypertension (PAH): phosphodiesterase 5 inhibitors (PDE5i); endothelin receptor antagonists; prostacyclin analogs; the IP receptor agonist selexipag; and the soluble guanylate cyclase (sGC) stimulator riociguat. For patients with inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH), riociguat is currently the only approved pharmacotherapy. Despite the development of evidence-based guidelines on appropriate use of specific drugs, in clinical practice patients are often prescribed PAH-targeted therapies off label or at inadequate doses. PDE5i are the most often prescribed class of drugs as initial therapy, either alone or in combination with other drug classes. However, a proportion of patients receiving PAH therapies do not reach or maintain treatment goals. As PDE5i and riociguat target different molecules in the nitric oxide-sGC-cyclic guanosine monophosphate (NO-sGC-cGMP) signaling pathway, for patients with PAH without an initial or sustained response to PDE5i, there is a biological rationale for switching to riociguat. However, robust data from randomized controlled trials on the safety and efficacy of switching are lacking, as is formal guidance for clinicians. Here we review studies of sequential combination therapy, and trial data and case studies that have investigated switching between PAH-approved therapies, particularly from PDE5i to riociguat in patients with PAH with an insufficient response to PDE5i, and in patients with CTEPH who were receiving off-label treatment. These studies summarize the current evidence and practical real-life experience on the concept of switching treatments.
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Affiliation(s)
- Raymond L. Benza
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul A. Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Centre, Giessen, Germany, member of the German Centre for Lung Research (DZL)
- Department of Medicine, Imperial College London, London, UK
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Gérald Simonneau
- Assistance Publique–Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d’Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and INSERM Unité 999, Le Kremlin–Bicêtre, France
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Vachiéry JL, Galiè N, Barberá JA, Frost AE, Ghofrani HA, Hoeper MM, McLaughlin VV, Peacock AJ, Simonneau G, Blair C, Miller KL, Langley J, Rubin LJ. Initial combination therapy with ambrisentan + tadalafil on pulmonary arterial hypertension‒related hospitalization in the AMBITION trial. J Heart Lung Transplant 2019; 38:194-202. [DOI: 10.1016/j.healun.2018.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/17/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022] Open
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Galiè N, Channick RN, Frantz RP, Grünig E, Jing ZC, Moiseeva O, Preston IR, Pulido T, Safdar Z, Tamura Y, McLaughlin VV. Risk stratification and medical therapy of pulmonary arterial hypertension. Eur Respir J 2019; 53:13993003.01889-2018. [PMID: 30545971 PMCID: PMC6351343 DOI: 10.1183/13993003.01889-2018] [Citation(s) in RCA: 529] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 01/15/2023]
Abstract
Pulmonary arterial hypertension (PAH) remains a severe clinical condition despite the availability over the past 15 years of multiple drugs interfering with the endothelin, nitric oxide and prostacyclin pathways. The recent progress observed in medical therapy of PAH is not, therefore, related to the discovery of new pathways, but to the development of new strategies for combination therapy and on escalation of treatments based on systematic assessment of clinical response. The current treatment strategy is based on the severity of the newly diagnosed PAH patient as assessed by a multiparametric risk stratification approach. Clinical, exercise, right ventricular function and haemodynamic parameters are combined to define a low-, intermediate- or high-risk status according to the expected 1-year mortality. The current treatment algorithm provides the most appropriate initial strategy, including monotherapy, or double or triple combination therapy. Further treatment escalation is required in case low-risk status is not achieved in planned follow-up assessments. Lung transplantation may be required in most advanced cases on maximal medical therapy. State of the art and research perspectives on medical therapy of pulmonary arterial hypertension, including treatment algorithmhttp://ow.ly/4UkJ30md5GS
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Affiliation(s)
- Nazzareno Galiè
- Dept of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Richard N Channick
- Pulmonary and Critical Care Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Frantz
- Dept of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ekkehard Grünig
- Pulmonary Hypertension Center, Thoraxklinic at Heidelberg University Hospital, Heidelberg, Germany
| | - Zhi Cheng Jing
- State Key Lab of Cardiovascular Disease, FuWai Hospital and Key Lab of Pulmonary Vascular Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Olga Moiseeva
- Non-Coronary Heart Disease Dept, Almazov National Medical Research Centre, St Petersburg, Russian Federation
| | - Ioana R Preston
- Tufts University School of Medicine, Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, MA, USA
| | - Tomas Pulido
- Cardiopulmonary Dept, National Heart Institute, La Salle University, Mexico City, Mexico
| | - Zeenat Safdar
- Pulmonary, Critical Care Division, Houston Methodist Hospital, Weill Cornell College of Medicine, Houston, TX, USA
| | - Yuichi Tamura
- Dept of Cardiology, International University of Health and Welfare School of Medicine, Tokyo, Japan
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Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. Eur Respir J 2019; 53:13993003.02148-2018. [PMID: 30552088 PMCID: PMC6351332 DOI: 10.1183/13993003.02148-2018] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 11/13/2018] [Indexed: 11/05/2022]
Abstract
Since 1973 the World Symposia on Pulmonary Hypertension (WSPH) proceedings have summarised the scientific advances and future needs in this field through the efforts of multiple task forces, each focusing on a different aspect of pulmonary hypertension (PH) [1]. The 6th WSPH comprised 124 experts, divided into 13 task forces, that began their work in January 2017 and presented their consensus opinions to an audience of 1376 participant attendees between February 27 and March 1, 2018 in Nice, France. A newly created task force dedicated to patients' perspectives, including representatives of patients' associations worldwide, was added for the 6th WSPH. State of the art summary on diagnosis, prognosis, therapy and future perspectives of pulmonary hypertensionhttp://ow.ly/8MHN30mGtqs
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Affiliation(s)
- Nazzareno Galiè
- Dept of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | - Lewis J Rubin
- University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Gerald Simonneau
- Univ. Paris-Sud, AP-HP, Centre de Référence de l'Hypertension Pulmonaire Sévère, Service de Pneumologie, Département Hospitalo-Universitaire (DHU) Thorax Innovation (TORINO), Hôpital de Bicêtre, Le Kremlin Bicêtre, France.,INSERM UMR_S999, LabEx LERMIT, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Beghetti M, Channick RN, Chin KM, Di Scala L, Gaine S, Ghofrani H, Hoeper MM, Lang IM, McLaughlin VV, Preiss R, Rubin LJ, Simonneau G, Sitbon O, Tapson VF, Galiè N. Selexipag treatment for pulmonary arterial hypertension associated with congenital heart disease after defect correction: insights from the randomised controlled GRIPHON study. Eur J Heart Fail 2019; 21:352-359. [PMID: 30632656 PMCID: PMC6607487 DOI: 10.1002/ejhf.1375] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/30/2018] [Accepted: 11/03/2018] [Indexed: 11/07/2022] Open
Abstract
Aims Patients with pulmonary arterial hypertension associated with congenital heart disease (CHD‐PAH) after defect correction have a poor prognosis compared with other CHD‐PAH patients. Therefore, it is important that these patients are treated as early and effectively as possible. Evidence supporting the use of PAH therapies in patients with corrected CHD‐PAH from randomised controlled trials is limited. The purpose of these analyses was to characterise the corrected CHD‐PAH patients from the GRIPHON study and examine the response to selexipag. Methods and results Out of the 110 patients diagnosed with corrected CHD‐PAH, 55 had atrial septal defects, 38 had ventricular septal defects, 14 had persistent ducti arteriosus, and 3 had defects not further specified. Hazard ratios (HR) and 95% confidence intervals (CI) for the primary composite endpoint were calculated using Cox proportional hazard models. Compared with the non‐CHD patients from GRIPHON, patients with corrected CHD‐PAH were slightly younger, with a greater proportion being treatment‐naive and in World Health Organization functional class I/II. The rate of the primary composite endpoint of morbidity/mortality was lower in patients with corrected CHD‐PAH who were treated with selexipag compared with those treated with placebo (HR 0.58; 95% CI 0.25, 1.37). The most common adverse events were those known to be related to selexipag. Conclusions These post‐hoc analyses of GRIPHON provide valuable information about a large population of patients with corrected CHD‐PAH, and suggest that selexipag may delay disease progression and was well‐tolerated in patients with corrected CHD‐PAH.
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Affiliation(s)
- Maurice Beghetti
- Pediatric Cardiology UnitCentre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique, University of Geneva and LausanneLausanneSwitzerland
| | - Richard N. Channick
- David Geffen School of Medicine, University of California Los AngelesLos AngelesCAUSA
| | - Kelly M. Chin
- Division of Internal MedicineUniversity of Texas SouthwesternDallasTXUSA
| | | | - Sean Gaine
- National Pulmonary Hypertension UnitMater Misericordiae University HospitalDublinIreland
| | - Hossein‐Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center of Lung Research, and Department of MedicineImperial College LondonLondonUK
| | - Marius M. Hoeper
- Department of Respiratory MedicineHannover Medical School and German Centre for Lung ResearchHannoverGermany
| | - Irene M. Lang
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | | | - Ralph Preiss
- Actelion Pharmaceuticals LtdAllschwilSwitzerland
| | - Lewis J. Rubin
- Department of MedicineUniversity of CaliforniaSan DiegoCAUSA
| | - Gérald Simonneau
- APHP, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs, CHU BicêtreUniversité Paris-Sud, Le Kremlin-BicêtreParisFrance
| | - Olivier Sitbon
- APHP, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs, CHU BicêtreUniversité Paris-Sud, Le Kremlin-BicêtreParisFrance
| | - Victor F. Tapson
- Division of Pulmonary and Critical Care Medicine, Department of MedicineCedars Sinai Medical CenterLos AngelesCAUSA
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES)Bologna University HospitalBolognaItaly
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Galiè N, Channick RN, Frantz RP, Grünig E, Jing ZC, Moiseeva O, Preston IR, Pulido T, Safdar Z, Tamura Y, McLaughlin VV. Risk stratification and medical therapy of pulmonary arterial hypertension. Eur Respir J 2019. [PMID: 30545971 DOI: 10.1183/13993003.01889-2018)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pulmonary arterial hypertension (PAH) remains a severe clinical condition despite the availability over the past 15 years of multiple drugs interfering with the endothelin, nitric oxide and prostacyclin pathways. The recent progress observed in medical therapy of PAH is not, therefore, related to the discovery of new pathways, but to the development of new strategies for combination therapy and on escalation of treatments based on systematic assessment of clinical response. The current treatment strategy is based on the severity of the newly diagnosed PAH patient as assessed by a multiparametric risk stratification approach. Clinical, exercise, right ventricular function and haemodynamic parameters are combined to define a low-, intermediate- or high-risk status according to the expected 1-year mortality. The current treatment algorithm provides the most appropriate initial strategy, including monotherapy, or double or triple combination therapy. Further treatment escalation is required in case low-risk status is not achieved in planned follow-up assessments. Lung transplantation may be required in most advanced cases on maximal medical therapy.
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Affiliation(s)
- Nazzareno Galiè
- Dept of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Richard N Channick
- Pulmonary and Critical Care Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Frantz
- Dept of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ekkehard Grünig
- Pulmonary Hypertension Center, Thoraxklinic at Heidelberg University Hospital, Heidelberg, Germany
| | - Zhi Cheng Jing
- State Key Lab of Cardiovascular Disease, FuWai Hospital and Key Lab of Pulmonary Vascular Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Olga Moiseeva
- Non-Coronary Heart Disease Dept, Almazov National Medical Research Centre, St Petersburg, Russian Federation
| | - Ioana R Preston
- Tufts University School of Medicine, Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, MA, USA
| | - Tomas Pulido
- Cardiopulmonary Dept, National Heart Institute, La Salle University, Mexico City, Mexico
| | - Zeenat Safdar
- Pulmonary, Critical Care Division, Houston Methodist Hospital, Weill Cornell College of Medicine, Houston, TX, USA
| | - Yuichi Tamura
- Dept of Cardiology, International University of Health and Welfare School of Medicine, Tokyo, Japan
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